Differentiation of atypical atrioventricular node re-entrant tachycardia from orthodromic reciprocating tachycardia using a septal accessory pathway by the response to ventricular pacing

OBJECTIVES

The purpose of this study was to determine whether the response to ventricular pacing during tachycardia is useful for differentiating atypical atrioventricular node re-entrant tachycardia (AVNRT) from orthodromic reciprocating tachycardia (ORT) using a septal accessory pathway.

BACKGROUND

Although it is usually possible to differentiate atypical AVNRT from ORT using a septal accessory pathway, a definitive diagnosis is occasionally elusive.

METHODS

In 30 patients with atypical AVNRT and 44 patients with ORT using a septal accessory pathway, the right ventricle was paced at a cycle length 10 to 40 ms shorter than the tachycardia cycle length (TCL). The ventriculo-atrial (VA) interval and TCL were measured just before pacing. The interval between the last pacing stimulus and the last entrained atrial depolarization (stimulus-atrial [S-A] interval) and the post-pacing interval (PPI) at the right ventricular apex were measured on cessation of ventricular pacing.

RESULTS

All 30 patients with atypical AVNRT and none of the 44 patients with ORT using a septal accessory pathway had an S-A-VA interval >85 ms and PPI-TCL >115 ms.

CONCLUSIONS

The S-A-VA interval and PPI-TCL are useful in distinguishing atypical AVNRT from ORT using a septal accessory pathway.

Synaptic transmission and its duplication by focally applied acetylcholine in parasympathetic neurons in the heart of the frog

Synaptic transmission has been analysed in parasympathetic nerve cells that lie in the transparent interatrial septum of the heart of the frog. Using Nomarski interference optics, one can see much cellular detail, including synaptic boutons in living preparations. 1. On each ganglion cell, the 10 to 20 synaptic boutons are usually derived from a single vagal nerve fibre. These fibres branch extensively to innervate a number of septal ganglion cells. 2. The chemical transmitter, acetylcholine (ACh), liberated by a presynaptic impulse survives for up to 40 ms, setting up an excitatory postsynaptic potential (e.p.s.p.) which triggers one and sometimes two action potentials in the postsynaptic cell. The e.p.s.p. is made up of quantal components, as at the neuromuscular junction. 3. Nerve-evoked e.p.s.p.s can be well matched in amplitude and time course by iontophoretic application of ACh to selected areas of the neuronal membrane. In particular, the miniature e.p.s.p., which is due to the focal release of a small quantity of transmitter, was accurately mimicked by iontophoretic application of ACh. By grading the amount of ACh released from an electrode one could also duplicate the wide variety of nerve-evoked postsynaptic discharges of ganglion cells. 4. The permeability changes initiated in the postsynaptic membrane by applied ACh and the synaptic transmitter appear identical, since the ionic fluxes for both responses have the same equilibrium potential. Also, the receptors which react with the synaptic transmitter are desensitized by applied ACh. 5. Cholinesterase inhibitors (Tensilon and Eserine) have a variable action on different cells, with respect both to nerve-evoked and Ach evoked potentials. The reasons for this variation are unclear, and need further study. 6. Miniature e.p.s.p.s resemble analogous potentials at nerve-muscle junctions and other synapses. A significant proportion of the min e.p.s.p.s is released as multiple units. This proportion is increased in high Ca2+, while single units alone occur in a low Ca2+-high Mg2+ environment. 7. The experiments provide information about the release of ACh from nerve terminals and its action on the postsynaptic membrane of neurons. They are in good agreement with analogous studies on skeletal neuromuscular junctions

Visual identification of synaptic boutons on living ganglion cells and of varicosities in postganglionic axons in the heart of the frog

1. Parasympathetic neurons were studied in the transparent interatrial septum of the frog (Rana pipiens) with light- and electron-microscopic techniques. The aim was to identify visually cellular and subcellular details in a living preparation, especially synaptic boutons on ganglion cells and the varicosities in postganglionic axons supplying the muscles of the heart. 2. The interatrial septum contains the following nervous elements: unipolar parasympathetic ganglion cells, their preganglionic vagal innervation, postganglionic sympathetic axons and sensory fibres. These structures and the nuclei of their related Schwann cells can be viewed with various optical systems, especially differential interference contrast optics. The same neural elements identified in the live preparation can be sectioned for electron microscopy. 3. Most ganglion cells are innervated by a single presynaptic axon, terminating in up to 27 synaptic boutons which on the average cover about 3.0 % of the surface of nerve cell bodies. A few scattered boutons also occur on the initial axonal portion of the ganglion cells. 4. Synaptic boutons on ganglion cells were recognized in the living unstained preparation. Their identity was confirmed by electron microscopy and by light microscopy combined with methylene blue, zinc iodide and osmium, and cholinesterase staining methods. 5. The terminal branches of postganglionic axons have numerous varicosities along their course. Some are as close as a few hundred angstroms (10 Å = 1 nm) to muscle fibres, others are many pm away. There are two types of varicosities: (i) those which contain predominantly granular vesicles characteristic of neurons releasing catecholamines, and (ii) those with predominantly agranular vesicles which belong to the cholinergic axons of septal ganglion cells. Regardless of their distance from muscle fibres, the cholinergic varicosities have the same fine structural features, including membrane thickenings, as synaptic boutons on the ganglion cells. These findings support earlier suggestions that the varicosities along postganglionic axons are a series of transmitter release sites. 6. Varicosities were observed in the live septum; their identity was confirmed by subsequent electron microscopy. Many live varicose axons were traced back to the vicinity of individual septal ganglion cells. Additional evidence that they belonged to a particular ganglion cell, and were therefore cholinergic, was obtained by injecting Procion yellow into the cell body and observing the neuron with a fluorescence microscope after the dye had spread into the axonal processes. Time lapse photography of up to 24 h showed no ‘ peristaltic ’ movement of varicosities. 7. Granular or agranular vesicles also occur along cylindrical axons within nerve bundles many pm away from muscle fibres. Like the vesicles in varicosities, they are clustered close to ‘thickenings’ in the surface membrane and belong to postganglionic nerve fibres. 8. Ganglion cells in isolated septa survive for 2 weeks or longer, still giving membrane potentials and impulses. Time lapse cinematography for up to 2 weeks after removing the septum showed that the organelles within the neurons were in motion and that a two-way traffic takes place between the cell body and axon, as commonly found in cultured neurons.

Nitric oxide synthase immunoreactivity and NADPH-diaphorase activity in a subpopulation of intrinsic neurones of the guinea-pig heart

This is the first report of the presence of nitric oxide synthase (NOS) immunoreactivity and NADPH-diaphorase (NADPH-d) activity in a subpopulation of the intrinsic neurones that innervate the heart. A cytochemical technique to detect NADPH-d and antisera raised against purified rat cerebellar NOS were employed to examine the expression of these enzymes by cells in a dissociated cell culture preparation from newborn guinea-pig atria and interatrial septum. Comparison of the results obtained by these two techniques and double-labelling experiments indicate that a subpopulation of intracardiac neurones contain both NADPH-d and NOS. These results indicate that some intracardiac neurones are capable of synthesizing nitric oxide. This raises the possibility that nitric oxide plays a role in the neural control of the heart.

Cryoablation for accessory pathways located near normal conduction tissues or within the coronary venous system in children and young adults

BACKGROUND

Cryoablation may offer advantages over radiofrequency (RF) ablation for certain arrhythmia substrates, such as septal accessory pathways (APs). Data for young patients, especially regarding recurrence risk, require expansion.

OBJECTIVES

The purpose of this study was to study institutional outcomes for cryoablation of APs located in potentially difficult septal regions for children and young adults.

METHODS

Cryoablation was attempted in 35 young patients (mean age 15.6 years) with 37 APs that were either close to normal conduction tissues or inside the coronary venous system. Outcomes were compared with previously published institutional data for RF ablation at these same locations.

RESULTS

Acute cryoablation success was achieved for 29 (78%) of 37 APs. Apart from permanent PR prolongation in one case and right bundle branch block in one other, there were no detrimental effects on normal conduction. At median follow-up of 207 days (range 2-695 days), AP conduction recurred for 13 (45%) of 29 ablated APs. Younger patient age and midseptal AP location correlated with higher likelihood of recurrence. Acute success rates for cryoablation were similar to RF ablation in our laboratory, but recurrence rates were significantly higher (P <.001).

CONCLUSION

Cryoablation yields acute success rates comparable with RF ablation for difficult septal APs in young patients. The risk of AP recurrence appears higher after cryoablation, although safety benefits may provide suitable compensation for this deficiency. Methods for creating more effective cryoablation lesions need to be explored.

Atrial Septostomy Decreases Sympathetic Overactivity in Pulmonary Arterial Hypertension

BACKGROUND

We have reported previously that the sympathetic nervous system is activated in patients with pulmonary arterial hypertension (PAH), and that this is only partly explained by a decrease in arterial oxygenation. Possible causes for increased muscle sympathetic nerve activity (MSNA) in patients with PAH include right atrial distension and decreased cardiac output. Both may be improved by atrial septostomy, but this intervention also further decreases arterial oxygenation. In the present study, we wanted to investigate the effect of atrial septostomy on MSNA in patients with PAH.

METHODS

We recorded BP, heart rate (HR), arterial O2 saturation (SaO2), and MSNA before and after atrial septostomy in PAH patients (mean [+/- SE] age, 48 +/- 5 years) and in closely matched control subjects. Measurements were also performed after septostomy, while SaO2 was brought to the preprocedure level by supplemental O2 therapy.

RESULTS

Compared to the control subjects (n = 10), the PAH patients (n = 11) had a lower mean BP (75 +/- 2 vs 96 +/- 3 mm Hg, respectively; p < 0.001), lower mean SaO2 (92 +/- 1% vs 97 +/- 0%, respectively; p < 0.001), increased mean HR (84 +/- 4 vs 68 +/- 3 beats/min; p < 0.01), and markedly increased mean MSNA (76 +/- 5 vs 29 +/- 2 bursts per minute; p < 0.001). Atrial septostomy decreased mean SaO2 (to 85 +/- 2%; p < 0.001) and mean MSNA (to 69 +/- 4 bursts per minute; p < 0.01), but did not affect HR or BP. Therapy with supplemental O2 did not affect MSNA, BP, or HR. The decrease in MSNA was correlated to the decrease in right atrial pressure (r = 0.62; p < 0.05).

CONCLUSIONS

Atrial septostomy in PAH patients decreases sympathetic hyperactivity despite an associated decrease in arterial oxygenation, and this appears to be related to decreased right atrial distension.

Preservation of atrioventricular nodal conduction during radiofrequency current catheter ablation of midseptal accessory pathways

BACKGROUND

Septal accessory atrioventricular (AV) pathways may be located in close vicinity of the His bundle-AV nodal conduction system. Attempts at surgical or electrical interruption of these pathways may therefore result in impairment of normal AV conduction. This study focuses on a subset of septal pathways with an atrial insertion located inside the triangle of Koch. In this study, they were called "midseptal."

METHODS AND RESULTS

Six patients with a midseptal accessory pathway (mean +/- SD age, 40 +/- 12 years; five with Wolff-Parkinson-White syndrome and one with a concealed accessory pathway) underwent attempts at ablation of their pathway using 500-kHz radiofrequency current applied to the atrial insertion of the accessory connection. Guided by the recording of accessory pathway activation potentials, the ablation catheter was positioned in all patients in an area bounded anteriorly by the tip electrode of the His bundle catheter and posteriorly by the coronary sinus ostium. All pathways were successfully ablated without the induction of complete heart block. First-degree AV conduction block occurred in one patient in whom a concealed accessory connection was located closer to the AV node than to the coronary sinus ostium.

CONCLUSIONS

Radiofrequency current catheter ablation may be used effectively for midseptal accessory pathways and should be preferred in experienced centers as a safe alternative to surgical therapy.

Anatomy of the atrioventricular junctions with regard to ventricular preexcitation

In the normal heart, the atrioventricular junctions surround the orifices of the mitral and tricuspid valves. The septal area of the junctions is much smaller than generally thought, being made up of the fibrous membranous septum and the muscular atrioventricular septum. The left atrioventricular junction gives the potential for muscular atrioventricular contiguities only in relation to the mural leaflet of the mitral valve. The right junction extends from the area posterior to the muscular atrioventricular septum to the supraventricular crest of the right ventricle. Anomalous pathways for conduction, which produce pre-excitation, can be found anywhere within these atrioventricular junctions. The pathways usually are the muscular accessory connections responsible for the Wolff-Parkinson-White syndrome, which can exist in the left, septal, or right junctions. Specific muscular connections are found in the presence of Purkinje cell tumors, diverticulums of the coronary sinus, or when taking origin from nodes of Kent at the acute margin of the ventricular mass. The latter connections are responsible for most examples of so-called Mahaim conduction, and are also described as atriofascicular tracts. The true Mahaim fibers are best described as nodoventricular or fasciculo-ventricular connections, while the pathway previously labelled as atriofascicular by the European Study Group is now best distinguished as an atrio-Hisian tract. The slow and fast pathways into the atrioventricular node are composed or ordinary atrial myocardium, the orientation of the fibers probably producing preferential conduction.

Localization of accessory pathways from the 12-lead electrocardiogram using a new algorithm

A new algorithm (St. George's algorithm), based on the polarity and morphology of QRS complexes rather than delta waves, was developed for localizing accessory pathways to 1 of 9 sites on the atrioventricular annuli. This was compared with algorithms previously proposed by Skeberis et al (localizing to 1 of 7 sites) and Milstein et al (localizing to 1 of 4 sites). The preexcited 12-lead electrocardiograms recorded during sinus rhythm in 106 consecutive patients (including 60 retrospectively analyzed patients and 46 prospectively analyzed patients) who underwent successful radiofrequency catheter ablation of a single accessory pathway were analyzed by 3 blinded observers using all 3 algorithms. The results were compared with the actual localization of accessory pathways as derived from endocardial mapping during catheter ablation. In all 106 patients, the accuracy of the 3 algorithms for 4 sites on the atrioventricular annuli (as considered by Milstein's method) was 72%, 79%, and 92% for Milstein's, Skeberis', and St. George's algorithms, respectively. For 7 sites (as considered by Skeberis' method), the accuracy was 65% (Skeberis' algorithm) and 88% (St. George's algorithm), and for 9 sites (as considered by our method) the accuracy was 86% (St. George's algorithm). In 46 prospectively analyzed patients, the accuracy of the 3 algorithms for 4 sites was 70% (Milstein's), 67% (Skeberis'), and 87% (St. George's); for 7 sites the accuracy was 61% (Skeberis') and 85% (St. George's), and for 9 sites the accuracy was 85% (St. George's). The reproducibility of St. George's and Skeberis' methods was better than that of Milstein's method.(ABSTRACT TRUNCATED AT 250 WORDS)

Spatial distribution and frequency dependence of arrhythmogenic vagal effects in canine atria

INTRODUCTION

Prior studies in isolated canine atria demonstrated that acetylcholine-induced reentrant atrial fibrillation (AF) was triggered by multifocal activity in the area of normal impulse origin (sinus node-crista terminalis). The aim of this study was to investigate the activation sequence in AF induced by vagal stimulation (VS) in intact dog hearts.

METHODS AND RESULTS

VS (10 to 50 Hz, 1 msec, 15 V, 5-sec trains) induced single or multiple atrial premature depolarizations (APDs), and/or AF in 8 of 10 open chest dogs. Occurrence of APDs and AF increased with increasing VS intensity. Epicardial mapping (254 unipolar electrodes) of both atria showed that APDs as a rule emerged from ectopic sites, often from the right atrial appendage. Activation mapping of the first 10 cycles of AF showed that only a small number (<3 to 4) of unstable reentrant circuits were possible at the same moment. Moreover, most sustained VS-induced AFs were accounted for by a single leading stable reentrant circuit that activated the remainder of the atria.

CONCLUSION

(1) Occurrence of vagally induced APDs and AF increases with increasing frequency of VS. (2) VS-induced focal ectopic APDs are widely distributed over the atria. (3) A single APD can be sufficient for initiation of reentrant AF. (4) Despite its high rate of sustained AF, it may be maintained by single stable reentrant circuit. (5) The atrial septum can play an important role in both the initiation and the maintenance of VS-induced AF.

Specific electrocardiographic features of manifest coronary vein posteroseptal accessory pathways

INTRODUCTION

Some posteroseptal accessory pathways (APs) can be successfully ablated by radiofrequency current only from inside the coronary sinus (CS) or its branches, because of an absolute or relatively epicardial location. The aim of this study was to identify ECG features of manifest posteroseptal APs requiring ablation in the CS or the middle cardiac veins (MCVs).

METHODS AND RESULTS

One hundred seventeen consecutive patients with manifest posteroseptal APs successfully ablated: (1) > or = 1 cm deep inside the MCV (group MCV: n = 13); (2) inside the CS, including the area adjacent to the MCV ostium (group CS: n = 10); (3) at the right (group R: n = 60); or (4) the left posteroseptal endocardial region (group L: n = 34) were included. We reviewed delta wave polarity (initial 40 msec) and QRS morphology during sinus rhythm and atrial pacing as well as electrogram characteristics in these patients. The local target site electrogram in groups MCV and CS was characterized by a longer atrial to ventricular electrogram interval, suggesting a longer course of the pathway and more frequent recording of a presumptive AP potential compared to the group ablated at the right or left endocardium. The most sensitive ECG feature for group CS or group MCV was a negative delta wave in lead II in sinus rhythm (87%), but specificity (79%) and positive predictive value (50%) were relatively low. A steep positive delta wave in aVR during maximal preexcitation possessed the highest specificity and positive predictive value (98% and 88%, sensitivity 61%) which increased to 99% and 91%, respectively, when combined with a deep S wave in V6 (R wave < or = S wave).

CONCLUSION

These data suggest that posteroseptal APs ablated inside the coronary venous system have highly specific features, including the combination of a steep positive delta wave in lead aVR and a deep S wave in lead V6 (R wave < or = S wave) during maximal preexcitation. The highest sensitivity is provided by a negative delta wave in lead II. These findings may be helpful for anticipating and planning an epicardial ablation strategy.

Long-term follow-up in patients with the permanent form of junctional reciprocating tachycardia treated with radiofrequency ablation

This study sought to determine the long-term follow-up, safety, and efficacy of radiofrequency catheter ablation of patients with the permanent form of junctional reciprocating tachycardia (PJRT). We assessed the reversibility of tachycardia induced LV dysfunction and we detailed the location and electrophysiological characteristics of these retrograde atrioventricular decremental pathways. PJRT is an infrequent form of reciprocating tachycardia, commonly incessant, and usually drug refractory. The ECG hallmarks include an RP interval > PR with inverted P waves in leads II, III, a VF, and V3-V6. During tachycardia, retrograde VA conduction occurs over an accessory pathway with slow and decremental conduction properties, located predominantly in the posteroseptal zone. It is known that long-lasting and incessant tachycardia may result in tachycardia induced severe ventricular dysfunction. We included 36 patients (13 men, 23 women, mean +/- SD, aged 44 +/- 22 years) with the diagnosis of PJRT. Seven patients had tachycardia induced left ventricular dysfunction. Radiofrequency energy was delivered at the site of earliest retrograde atrial activation during ventricular pacing or during reciprocating tachycardia. All patients were followed at the outpatient clinic and serial echocardiograms were performed in those who presented with depressed LV function. Radiofrequency ablation was performed in 36 decremental accessory pathways. Earliest retrograde atrial activation was right posteroseptal in 32 patients (88%), right mid-septal in 2 (6%), right posterolateral in 1 (3%), and left anterolateral in 1 (3%). Thirty-five accessory pathways were successfully ablated with a mean of 5 +/- 3 applications. A mid-septal accessory pathway could not be ablated. After a mean follow-up of 21 +/- 16 months (range 1-64) 34 patients are asymptomatic. There were recurrences in 8 patients after the initial successful ablation (mean of 1.2 months), 5 were ablated in a second ablation procedure, 2 patients required a third procedure, and 1 patient required four ablation sessions. All patients with LV dysfunction experienced a remarkable improvement after ablation. Mean preablation LV ejection fraction in patients with tachycardiomyopathy was 28% +/- 6% and rose to 51% +/- 16% after ablation (P < 0.02). Our study supports the concept that radiofrequency catheter ablation is a safe and effective treatment for patients with PJRT. Radiofrequency ablation should be the treatment of choice in these patients because this arrhythmia is usually drug refractory. The majority of accessory pathways are located in the posteroseptal zone. Cessation of the arrhythmia after successful ablation results in recovery of LV dysfunction.

Differential chemosensitivity of synaptic and extrasynaptic areas on the neuronal surface membrane in parasympathetic neurons of the frog, tested by microapplication of acetylcholine

1. The chemosensitivity of the surface of parasympathetic neurons in the interatrial septum of the heart of the frog has been explored by focal iontophoretic application of acetylcholine (ACh). 2. There is a specific highly chemosensitive area on the cell surface near synaptic boutons. ACh released close to visually identified boutons produced depolarizing responses which arise more rapidly and are larger than responses evoked at randomly chosen spots on the neuronal surface. 3. Individual synapses, or small numbers of them, can be desensitized by applied ACh without blocking synaptic transmission at nearby synapses on the same neuron. This shows that the method of ACh application resolves chemosensitivity in patches restricted to a few micrometres in diameter.

Ventricular activation process in minipigs

Because the form of QRS from the body surface of pigs is different from that of carnivores or ungulates, and because that form is dependent upon pathways of ventricular activation, this study was designed to study pathways of ven tricular activation in pigs. Twelve pigs were anesthetized and right or left hemithoracotomies were performed to expose the heart. Contiguous bipolar electrograms were recorded from button electrodes on the epicardium and from both faces of the interventicular septum, and from multipolar plunge electrodes introduced into the intramural regions of both ventricles. Electrograms were recorded simultaneous with the Z-axis ECG at 625 mm/sec paper speed on a photographic oscillograph. Times of arrival of waves of activation at numerous points in the ventricle were referenced to the peak of the R-wave in the Z-axis ECG. During the initial 10 msec of QRS, the apical-third of the interventricular septum is activated from left to right. During the next 40 msec of QRS, waves of activation originating at the cranial portion of the right ventricle and the caudal portion of the left ventricle engulf the epicardium toward the interventricular septum and slightly in an apico-basilar direction. Activity begins slightly earlier at the caudal aspect of the left ventricular free-wall and terminates on the pulmonary conus region. During the terminal 30 msec of QRS, the basilar third of the interventricular septum is activated in a general apico-basilar direction. Through regions of either right or left ventricular free-walls was a general endocardial to epicardial activation observed. These pathways of ventricular activation may be explained by the rather complete penetration of Purkinje fibers through both ventricular free-walls in a manner similar to that of ungulates but different from carnivores and primates.

Co-expression of four muscarinic receptor genes by the intrinsic neurons of the rat and guinea-pig heart

Expression of the messenger RNAs encoding the five different muscarinic acetylcholine receptor subtypes was examined in intracardiac neurons from the rat and guinea-pig heart by in situ hybridization techniques. Newborn guinea-pig intracardiac neurons were studied in dissociated cell culture preparations employing both 35S- and digoxigenin-labelled oligonucleotide probes specific for the m1, m2, m3, m4 or m5 muscarinic receptor messenger RNAs. When 35S-tailed oligonucleotides were used, all intracardiac neurons in culture were found to express m1, m2, m3 and m4, but not m5 messenger RNAs. However after hybridization with digoxigenin-tailed probes, only m1 and m2 transcripts were detected. This may reflect differences in the sensitivity of the two techniques. Further to these experiments, intracardiac ganglia in sections of adult rat heart were studied employing m1-, m2-, m3- or m4-specific, 35S-labelled oligonucleotides, and again, all intracardiac neurons expressed messenger RNA for each of these four muscarinic receptor subtypes. Atrial myocytes in culture were only labelled by [35S]- and digoxigenin-tailed m2 oligonucleotides. No other heart cell type seen expressed messenger RNA for any of the muscarinic receptors. The expression of four different muscarinic receptor transcripts by intrinsic neurons of the heart provides the molecular basis for the diverse muscarinic actions observed in these and other autonomic ganglia.

The number of synaptic boutons terminating on Xenopus cardiac ganglion cells is directly correlated with cell size

The relationship between the size of parasympathetic neurones and the number of synaptic boutons terminating upon them has been studied in the cardiac ganglion of Xenopus laevis. Synaptic boutons were visualized by impregnation with zinc iodide and osmium (ZIO), which by electron microscopy was shown to stain heavily all synaptic boutons in six preparations. Light microscopic examination of the unipolar ganglion cells in intact tissue reveals that larger neurones have more synaptic boutons. The number of boutons terminating on the cell body is significantly correlated with its surface area. By statistical means it was possible to demonstrate that the relation between bouton number and surface area is linear and that the regression line has a y-intercept not significantly different from zero. Therefore the density of synaptic boutons, one per 127 micron2 of cell body surface, is independent of cell size. The size of synaptic boutons, measured as the area of apposition between bouton and cell body, is similar for small and for large ganglion cells; thus a constant fraction (2%) of the cell body on average is covered by synaptic boutons, regardless of cell size. The correlation between bouton number and cell body surface area is not the result of interaction between boutons. The frequency distribution of boutons per normalized cell was found to be similar to that expected from the Poisson distribution. Thus the probability that a bouton will be 'assigned' to a particular cell is independent of how many other boutons are present. The only factor that appears to influence the number of boutons on the cell body is its size.

Electrophysiology of parasympathetic neurones isolated from the interatrial septum of bull-frog heart

1. Whole-cell voltage-clamp techniques were used to study the voltage-dependent membrane conductances in parasympathetic neurones enzymatically isolated from the interatrial septum of bull-frog heart and maintained in short-term (1-10 day) tissue culture. 2. The resting potential of the isolated neurones averaged -55.4 +/- 1.1 mV (+/- S.E.M., n = 11). Action potentials evoked in the isolated cells by brief (1-2 ms) current injections were similar to those recorded from neurones in the 'intact' septum. The amplitude of action potentials of isolated neurones averaged about 113 mV, with a peak depolarization of +32.8 +/- 2.8 mV and after-hyperpolarization of -80.0 +/- 2.8 mV. 3. The pattern of membrane currents recorded using voltage clamp with 'normal' external (containing 110 mM-Na+) and internal (110 mM-K+) solutions consisted of a rapidly activating and inactivating inward current followed by a slower, sustained outward current. 4. The inward components of current were isolated by using an internal solution in which Cs+ and TEA+ (tetrathylammonium) ions replaced K+. Depolarizations from holding potentials of -50 to -70 mV produced inward currents which had an initial transient phase followed by a maintained, or very slowly inactivating, component. The current-voltage relation for the initial transient phase reached a peak at membrane potentials near 0 mV, while the maintained phase, measured, for example, at the end of 50 ms voltage-clamp steps, had its peak near +10 mV. 5. The transient component of inward current was carried primarily by Na+ ions, as replacement of Na+ by TEA+ in the external solution abolished the transient. This current was thus identified as a voltage-dependent Na+ current, INa. The maintained component was greatly attenuated by removing 80-90% of the external Ca2+ ions, and it was abolished by divalent cations such as Cd2+ (0.2-0.4 mM), Ni2+ (0.5 mM) and La3+ (10-100 microM). This maintained component was thus a voltage-dependent calcium current, ICa. 6. About 80% of INa recorded in the presence of low (0.2-0.5 mM) external Ca2+ and 2 microM-LaCl3 was blocked by tetrodotoxin (TTX) with an apparent Kd of about 8 nM. The remaining 20% of INa was resistant to block by 2-10 microM-TTX. However, the 'TTX-resistant' component of INa was blocked by Cd2+ (0.2-0.4 mM). 7. The voltage-dependent calcium current, ICa, measured in saline in which Na+ was replaced by N-methyl-D-glucamine, activated near -40 mV and reached a peak near +10 to +15 mV.(ABSTRACT TRUNCATED AT 400 WORDS)

Optimization of right ventricular lead position in cardiac resynchronisation therapy

BACKGROUND

The benefit of biventricular pacing (BiV) may be substantially affected by optimal lead placement.

AIM

To evaluate the importance of right ventricular (RV) lead positioning on clinical outcome of BiV.

METHODS AND RESULTS

A total of 99 patients with symptomatic heart failure and implantation of BiV system were included. Position of the left-ventricular (LV) lead was selected based on timing of local endocardial signal within the terminal portion of the QRS complex. RV lead was preferably positioned at the midseptum (n=74, RVS group) where the earliest RV endocardial signal was recorded. A subgroup of patients had RV lead placed in the apex (n=25, RVA group). NYHA class, maximum oxygen-uptake (VO(2)max), LV end-diastolic diameter (LVEDD, mm) and ejection fraction were assessed every third month. A trend towards greater improvement in NYHA class and significant increase in VO(2)max was present in the RVS group. Moreover, a significant decrease in LVEDD (DeltaLVEDD) was observed in the RVS group only (-3.4+/-6.5 mm versus +1.7+/-6.4 mm in RVA group at 12 months, p=0.004). No significant correlation between the degree of DeltaLVEDD and QRS narrowing induced by BiV was found. LVEDD reduction was predominantly present in dilated cardiomyopathy.

CONCLUSIONS

Midseptal positioning of the RV lead appears to promote reverse LV remodelling during cardiac resynchronisation therapy.

Localization of precise origin of idiopathic ventricular tachycardia from the right ventricular outflow tract by a 12-lead ECG: a study of pace mapping using a multielectrode "basket" catheter

Radiofrequency catheter ablation guided by pace-mapping techniques has proven effective in eliminating idiopathic ventricular tachycardia (VT) originating from the right ventricular outflow tract (RVOT). A method for rapidly identifying the origin of VT from 12-lead electrocardiogram (ECG) findings would be helpful for the catheter ablation procedure. The purpose of this study is to precisely localize the origin of idiopathic VT from the RVOT by a 12-lead ECG from a study of multipoint pace mapping. In one patient with premature ventricular complex (PVC) and 3 with VT, a "basket" catheter was deployed in the RVOT for bipolar pacing from 56 sites in the endocardium of RVOT. Under fluoroscopy the pacing sites were classified into the septum and free wall. We investigated the QRS morphology in leads, I, II, and III; the depth of the QS wave in leads aVR and aVL; and the height of the initial r wave in leads V1 and V2. Pacing was captured in 30-47 of 56 sites (54%-84%). As the pacing sites changed from the anterior to posterior of the septum, the QS notch (-) type in lead I shifted through rs to R, while a shift from R type to rR' or Rr' was noted in leads II and III. As the pacing sites changed from the anterior to posterior of the free wall, lead I showed a shift from the QS notch (+) type to R, while a shift from rR' to Rr' (or rR' unchanged) was found in leads II and III. The depth of the QS wave in leads aVR and aVL showed a tendency for aVR to be deeper than aVL toward the posterolateral attachment of both the septum and free wall, whereas aVL tended to be deeper than aVR toward the anterior attachment. The initial r waves in V1 and V2 became greater as the pacing site was positioned at a higher or more posterior location. These findings may provide more precise and clinically useful diagnostic information on the site of the origin of idiopathic VT originating from the RVOT by a 12-lead ECG.

Cardiac sympathetic denervation predicts PD in at-risk individuals

INTRODUCTION

By the time a person develops the motor manifestations of Parkinson's disease (PD), substantial loss of nigrostriatal dopamine neurons has already occurred. There is great interest in identifying biomarkers that can detect pre-clinical PD. Braak's neuropathological staging concept imputes early autonomic involvement. Here we report results from a small prospective cohort study about the utility of neuroimaging evidence of cardiac sympathetic denervation in predicting PD among individuals with multiple PD risk factors.

METHODS

Subjects provided information about family history of PD, olfactory dysfunction, dream enactment behavior, and orthostatic hypotension at a protocol-specific website. From this pool, 27 people with at least 3 risk factors confirmed underwent cardiac 18F-dopamine positron emission tomographic scanning and were followed for at least 3 years. Interventricular septal and left ventricular free wall concentrations of 18F-dopamine-derived radioactivity were measured.

RESULTS

Of the 27 subjects, 4 were diagnosed with PD within the 3-year follow-up period (Pre-Clinical PD group); 23 risk-matched (mean 3.2 risk factors) subjects remained disease-free (No-PD group). Compared to the No-PD group, the Pre-Clinical PD group had lower initial values for septal and free wall concentrations of 18F-dopamine-derived radioactivity (p = 0.0248, 0.0129). All 4 Pre-Clinical PD subjects had evidence of decreased cardiac sympathetic innervation in the interventricular septum or left ventricular free wall, in contrast with 3 of 23 (13%) No-PD subjects (p = 0.0020 by Fisher's exact test).

CONCLUSION

People with multiple PD risk factors and diagnosed with PD within 3 years have evidence of antecedent cardiac sympathetic denervation. The findings fit with Braak's staging concept.

Membrane properties and firing characteristics of rat cardiac neurones in vitro

Electrophysiological characteristics of neurones in isolated cardiac ganglia from the left atrium and interatrial septum of the rat were studied with intracellular microelectrodes. At rest the neurones were characterized by a membrane potential of -52.6 +/- 0.83 mV, an input resistance of 85.6 +/- 7.6 M omega, a membrane time constant of 4.6 +/- 0.24 ms and an input capacitance of 63.1 +/- 5.25 pF. Removal of Ca2+ ions from the external solution resulted in a membrane depolarisation of 5.5 +/- 0.70 mV and an increase in input resistance of 96 +/- 52% which indicated that a substantial Ca(2+)-sensitive component contributed to resting membrane potential. A prolonged after-hyperpolarization (AHP) was recorded following a train of spikes; this was inhibited in a Ca(2+)-free solution, indicating that a Ca(2+)-sensitive component of potassium conductance contribute to it. On the basis of the duration of the AHP following a single spike, two types of neurones, I and II, were tentatively identified, having short (less than 300 ms) and long (greater than 300 ms) AHPs, respectively. Type I neurones responded to prolonged membrane depolarization with bursts of firing (Ib neurones) or multiple discharges (Im neurones). Type II neurones also responded with single spikes or multiple discharges to prolonged membrane depolarization. In some Im neurones, tonic firing was recorded which was inhibited by a hyperpolarizing current and accelerated by a depolarizing current injected through the recording microelectrode. Thus, neurones of isolated cardiac ganglia of the rat from the region studied here are heterogeneous in their electrical behaviour, suggesting the existence of functionally different groups within the ganglia.

Choline acetyltransferase in the heart of adult rats

The distribution of choline acetyltransferase (ChAT, EC 2.3.1.6.) in the heart of adult rats has been reinvestigated in view of recent discoveries that acetylcholine (ACh) can be synthesized not only by ChAT, but also by carnitine acetyltransferase (CarAT, EC 2.3.1.7) and that it is possible to distinquish between the ACh-synthesizing activity of ChAT in intramuscular nerves and the CarAT-mediated extraneural synthesis of ACh by means of bromoacetylcholine (BrACh), a specific inhibitor of ChAT. BrACh (0.002 mmol/l) has been found to inhibit the synthesis of ACh in the atria by 66-85% and in the ventricles by only 19-29%. Bromoacetylcarnitine (BrACar, 0.02 mmol/l), and inhibitor of CarAT, inhibited the synthesis of ACh in the atria by 34% and in the ventricles by 74-80%. These findings indicate that ChAT is responsible for most of the synthesis of ACh observed in the homogenates of the atria; in the ventricles, it catalyses only a minor portion of the total ACh synthesis observed. In the investigation of the regional distribution of ChAT in the heart, the BrACh-sensitive part of ACh synthesis was taken as the measure of ChAT activity. The highest activity of ChAT (nmol ACh synthesized g-l.h-l) was found in the region of the sinoatrial node (1775); it decreased in the order: interatrial septum (781) greater than rest of the right atrium (712) greater than left atrium (416) greater than basal part of the right ventricle (366) greater than apical part of the right ventricle (250) greater than inter-ventricular septum (239) greater than basal and apical part of the left ventricle (208 and 205). The results indicate that earlier investigations of the distribution of ChAT in the heart provided a basically correct picture although the contribution of CarAT to the synthesis of ACh measured had not been excluded, and confirm that ChAT is present throughout the heart, including the apical parts of the ventricles, However, the sino-atrio-ventricular gradient of ChAT distribution is steeper when the contribution of CarAT to the synthesis of ACh is excluded.

Synaptic transmission in rat cardiac neurones

Intracellular recordings of spontaneous synaptic activity and synaptic responses to fibre tract stimulation were taken from neurones of ganglia isolated from the left atrium and interatrial septum of the rat. In six out of 57 neurones studied, spontaneous fast excitatory postsynaptic potentials (EPSPs) were recorded. Single stimulation of fibre tracts approaching the ganglion resulted in an all-or-none response consisting of an EPSP, from which an action potential abruptly appeared. This response disappeared in Ca(2+)-free/high-Mg2+ solution, indicating that it was orthodromic in origin. EPSPs were markedly exaggerated and prolonged by neostigmine (1-5 microM). EPSPs produced by high-frequency (0.1-20 Hz) fibre tract stimulation were markedly attenuated when compared with responses to single fibre tract stimulation, although they usually remained suprathreshold for spike initiation. High concentrations of hexamethonium (1 mM) and d-tubocurarine (300 microM) failed to inhibit responses to single fibre tract stimulation, although they completely abolished responses to high-frequency stimulation. Responses to single fibre tract stimulation were abolished by trimetaphan (greater than or equal to 100 microM). No slow synaptic responses were detected during single or high-frequency fibre tract stimulation. All cardiac neurones that responded orthodromically were highly excitable: they had a short post-spike after-hyperpolarization (AHP) and responded with multiple firing to prolonged membrane depolarization. It is concluded that cardiac neurones, in the region of the heart studied here, receive single 'strong' cholinergic inputs from some fibre tracts approaching the ganglion that elicit EPSPs accompanied by spikes. EPSPs are rather resistant to ganglion-blocking agents and subject to frequency modulation.

Muscarinic modulation of calcium current in neurones from the interatrial septum of bull-frog heart

1. The effects of activation of muscarinic receptors on the voltage-dependent calcium current, ICa, in parasympathetic neurones were examined. 2. Neurones were enzymatically isolated from the interatrial septum of bull-frog (Rana catesbeiana) heart, and were maintained in short-term (1-6 day) tissue culture. ICa was recorded from the cells using whole-cell patch-clamp methods (Clark, Tse & Giles, 1990). 3. External application of 2 nM to 10 microM acetylcholine (ACh) reduced the amplitude and slowed the time course of activation of ICa. These effects were dependent on membrane potential; they were most pronounced at potentials near the peak of the current-voltage relation for ICa (i.e. +10 to +15 mV), whereas at more-negative potentials (i.e. -15 to -25 mV) the effects on both amplitude and time course were relatively small. 4. Atropine (1 microM) completely blocked the action of 1 microM-ACh, indicating that the effects of ACh on ICa were mediated by activation of muscarinic receptors. 5. Other muscarinic agonists, such as carbamylcholine (0.1-10 microM), DL-muscarine (0.1-2.5 microM) and oxotremorine (5 microM), had similar effects on ICa to ACh. 6. A guanine nucleotide-binding protein (G-protein) is involved in this muscarinic inhibition of ICa. Inclusion of the non-hydrolysable guanosine triphosphate analogue guanosine 5'-O-(3-thiotriphosphate) (GTP-gamma-S; 200 microM) in the intracellular solutions mimicked the effects of ACh, and application of external ACh in the presence of internal GTP-gamma-S produced smaller changes in ICa than in control conditions. Inclusion of another non-hydrolysable analogue, guanosine 5'-O-(2-thiodiphosphate) (GDP-beta-S; 0.5-5 mM), blocked the inhibitory effect of ACh on ICa. 7. The G-protein involved in the inhibition of ICa was sensitive to pertussis toxin (islet-activating protein; IAP). The inhibition of ICa by carbamylcholine (5 microM) was reduced by about 90% after incubating cells for 12-15 h in culture medium containing 200 ng/ml IAP. 8. The possible roles of cyclic AMP or cyclic GMP-dependent protein kinases, or protein kinase C, in the muscarinic inhibition of ICa were tested, but these enzymes appear not to be directly involved.

Electrocardiographic identification of mid-septal accessory pathways in close proximity to the atrioventricular conduction system

In order to identify ECG characteristics of overt mid-septal accessory pathways (APs) predictive of close proximity to the AV conduction system we analyzed data from patients who underwent successful RF catheter ablation of a mid-septal AP. Mean patient age was 31 +/- 16 years, and 13 were male. The 40 degrees right anterior oblique view was used to divide the mid-septal area into 3 zones: 1 (anterior portion); 2 (intermediate); and 3 (posterior portion). The 12-lead ECG was analyzed with regard to delta wave polarity and R/S transition in the precordial leads. The findings from patients ablated at zone 3 were compared to those at zones 1 and 2. All patients had a positive delta wave in the leads I, II, aVL, and negative delta wave in the leads III and aVR. The R/S transition occurred in lead V2 in 80% of patients. The delta wave in lead aVF was the only ECG characteristic that correlated with the AP ablation zone. Six of 8 patients ablated at zone 3 had a negative delta wave in lead aVF while 6 out of 7 patients ablated at zone 1 or 2 had a positive or isoelectric delta wave in lead aVF (P = 0.03). A positive or isoelectric delta wave in lead aVF identifies mid-septal AP in close proximity to the AV conduction system.