Purkinje Network Research Articles

Harnessing 12-lead ECG and MRI data to personalise repolarisation profiles in cardiac digital twin models for enhanced virtual drug testing

Cardiac digital twins are computational tools capturing key functional and anatomical characteristics of patient hearts for investigating disease phenotypes and predicting responses to therapy. When paired with large-scale computational resources and large clinical datasets, digital twin technology can enable virtual clinical trials on virtual cohorts to fast-track therapy development. Here, we present an open-source automated pipeline for personalising ventricular electrophysiological function based on routinely acquired magnetic resonance imaging (MRI) data and the standard 12-lead electrocardiogram (ECG).Using MRI-based anatomical models, a sequential Monte-Carlo approximate Bayesian computational inference method is extended to infer electrical activation and repolarisation characteristics from the ECG. Fast simulations are conducted with a reaction-Eikonal model, including the Purkinje network and biophysically-detailed subcellular ionic current dynamics for repolarisation. For each patient, parameter uncertainty is represented by inferring an envelope of plausible ventricular models rather than a single one, which means that parameter uncertainty can be propagated to therapy evaluation. Furthermore, we have developed techniques for translating from reaction-Eikonal to monodomain simulations, which allows more realistic simulations of cardiac electrophysiology. The pipeline is demonstrated in three healthy subjects, where our inferred pseudo-diffusion reaction-Eikonal models reproduced the patient's ECG with a median Pearson's correlation coefficient of 0.9, and then translated to monodomain simulations with a median correlation coefficient of 0.84 across all subjects. We then demonstrate our digital twins for virtual evaluation of Dofetilide with uncertainty quantification. These evaluations using our cardiac digital twins reproduced dose-dependent QTc and T peak to T end prolongations that are in keeping with large population drug response data.The methodologies for cardiac digital twinning presented here are a step towards personalised virtual therapy testing and can be scaled to generate virtual populations for clinical trials to fast-track therapy evaluation. The tools developed for this paper are open-source, documented, and made publicly available.

Catheter Ablation for Channelopathies: When Is Less More?

Ventricular fibrillation (VF) is a common cause of sudden cardiac death in patients with channelopathies, particularly in the young population. Although pharmacological treatment, cardiac sympathectomy, and implantable cardioverter defibrillators (ICD) have been the mainstay in the management of VF in patients with channelopathies, they are associated with significant adverse effects and complications, leading to poor quality of life. Given these drawbacks, catheter ablation has been proposed as a therapeutic option for patients with channelopathies. Advances in imaging techniques and modern mapping technologies have enabled increased precision in identifying arrhythmia triggers and substrate modification. This has aided our understanding of the underlying pathophysiology of ventricular arrhythmias in channelopathies, highlighting the roles of the Purkinje network and the epicardial right ventricular outflow tract in arrhythmogenesis. This review explores the role of catheter ablation in managing the most common channelopathies (Brugada syndrome, congenital long QT syndrome, short QT syndrome, and catecholaminergic polymorphic ventricular tachycardia). While the initial results for ablation in Brugada syndrome are promising, the long-term efficacy and durability of ablation in different channelopathies require further investigation. Given the genetic and phenotypic heterogeneity of channelopathies, future studies are needed to show whether catheter ablation in patients with channelopathies is associated with a reduction in VF, and psychological distress stemming from recurrent ICD shocks, particularly relative to other available therapeutic options (e.g., quinidine in high-risk Brugada patients).

Digital twinning of the human ventricular activation sequence to Clinical 12-lead ECGs and magnetic resonance imaging using realistic Purkinje networks for in silico clinical trials

Cardiac in silico clinical trials can virtually assess the safety and efficacy of therapies using human-based modelling and simulation. These technologies can provide mechanistic explanations for clinically observed pathological behaviour. Designing virtual cohorts for in silico trials requires exploiting clinical data to capture the physiological variability in the human population. The clinical characterisation of ventricular activation and the Purkinje network is challenging, especially non-invasively. Our study aims to present a novel digital twinning pipeline that can efficiently generate and integrate Purkinje networks into human multiscale biventricular models based on subject-specific clinical 12-lead electrocardiogram and magnetic resonance recordings. Essential novel features of the pipeline are the human-based Purkinje network generation method, personalisation considering ECG R wave progression as well as QRS morphology, and translation from reduced-order Eikonal models to equivalent biophysically-detailed monodomain ones. We demonstrate ECG simulations in line with clinical data with clinical image-based multiscale models with Purkinje in four control subjects and two hypertrophic cardiomyopathy patients (simulated and clinical QRS complexes with Pearson's correlation coefficients > 0.7). Our methods also considered possible differences in the density of Purkinje myocardial junctions in the Eikonal-based inference as regional conduction velocities. These differences translated into regional coupling effects between Purkinje and myocardial models in the monodomain formulation. In summary, we demonstrate a digital twin pipeline enabling simulations yielding clinically consistent ECGs with clinical CMR image-based biventricular multiscale models, including personalised Purkinje in healthy and cardiac disease conditions.

Branched Latent Neural Maps

We introduce Branched Latent Neural Maps (BLNMs) to learn finite dimensional input–output maps encoding complex physical processes. A BLNM is defined by a simple and compact feedforward partially-connected neural network that structurally disentangles inputs with different intrinsic roles, such as the time variable from model parameters of a differential equation, while transferring them into a generic field of interest. BLNMs leverage latent outputs to enhance the learned dynamics and break the curse of dimensionality by showing excellent in-distribution generalization properties with small training datasets and short training times on a single processor. Indeed, their in-distribution generalization error remains comparable regardless of the adopted discretization during the testing phase. Moreover, the partial connections, in place of a fully-connected structure, significantly reduce the number of tunable parameters. We show the capabilities of BLNMs in a challenging test case involving biophysically detailed electrophysiology simulations in a biventricular cardiac model of a pediatric patient with hypoplastic left heart syndrome. The model includes a 1D Purkinje network for fast conduction and a 3D heart-torso geometry. Specifically, we trained BLNMs on 150 in silico generated 12-lead electrocardiograms (ECGs) while spanning 7 model parameters, covering cell-scale, organ-level and electrical dyssynchrony. Although the 12-lead ECGs manifest very fast dynamics with sharp gradients, after automatic hyperparameter tuning the optimal BLNM, trained in less than 3 h on a single CPU, retains just 7 hidden layers and 19 neurons per layer. The resulting mean square error is on the order of 10−4 on an independent test dataset comprised of 50 additional electrophysiology simulations. In the online phase, the BLNM allows for 5000x faster real-time simulations of cardiac electrophysiology on a single core standard computer and can be employed to solve inverse problems via global optimization in a few seconds of computational time. This paper provides a novel computational tool to build reliable and efficient reduced-order models for digital twinning in engineering applications. The Julia implementation is publicly available under MIT License at https://github.com/StanfordCBCL/BLNM.jl.

The weakest point of cardiac resynchronization therapy: new technologies facing old terminology.

Patients with symptomatic heart failure (HF) and left bundle branch block (LBBB) are currently treated with biventricular pacing (BiV) which has a Class IA recommendation. Given the possibility to re-establish the inter and intra-ventricular synchrony, BiV is commonly referred to as cardiac resynchronization therapy (CRT). This wording is widely utilized and over time the terms BiV and CRT have become interchangeable. Conduction system pacing (CSP) is emerging as a valid therapeutic opportunity to obtain CRT restoring the native conduction via the Purkinje network. Therefore the acronym CRT is no longer synonymous with BiV only but could also refer to CSP. A terminology update is needed to include the resource of CSP to ensure better communication among all the stakeholders involved in managing recipients of cardiac devices and should be a fundamental step in advancing the quality of patient care. Making use of the NBG code to describe the implantable cardiac device would ease such terminology update, since only the first three positions of the five letters NBG code are commonly utilized, while the last two are rarely used.

Abstract P3138: Potentiation Mechanism Of SR-Ca2+ Uptake During Myocardial Infarction; A Molecular Explanation Of Ca2+ Arrhythmogenicity Of Purkinje Fibers In The Ischemic Heart.

Experimental and clinical evidence attributes lethal VTs and VFs associated with ischemic myocardial infarctions ( MI ) to abnormal electric signaling in the Purkinje network. In cardiac Purkinje cells ( Pcells ), spontaneous Ca 2+ releases from the sarcoplasmic reticulum ( SR-CaR ) generate depolarizing Ca 2+ waves which, in turn, can mediate DADs and non-driven APs. Increase of SR-CaR was reported in Pcells of dog heart with 48Hrs MI. An augmentation of SR-Ca 2+ uptake ( SR-CaU ) accelerates SR-Ca 2+ recycling and is a possible cause of larger (pro-arrhythmic) SR-CaR in Pcells of ischemic heart. We tested this hypothesis in canine and porcine models of acute MI.Pcells and heart tissues were prepared 48Hrs after LAD coronary artery ligation. Intracellular Ca 2+ activity was captured by confocal microscopy. SR-CaU was studied by analyzing Purkinje-typical Ca 2+ events, namely Ca 2+ -sparks, peripheral Ca 2+ -wavelets and cell-wide Ca 2+ -waves ( CWW s). Relevance of our analysis was tested with a Purkinje-specific model of Ca 2+ mobilization. Protein/gene expressions of SR-Ca 2+ pump isoforms were studied by immunofluorescence, WBs, and qPCR in dog and pig infarcted tissues.We found that (1) individual Ca 2+ release sites in MI Pcells fired sparks at 61% larger frequency, (2) the duration of wavelet Ca 2+ decay was reduced by 25% due to 37% acceleration of cytosolic Ca 2+ removal (time constant: 156±21ms (Normal; n=10) vs 98±9ms (MI; n=16; P<0.01)), (3) wavelet amplitude was increased by 50%, and (4) larger waves (CWWs) showed similar alterations. Numerical replication of MI wavelets succeeded with 52% increase of Ca 2+ uptake rate in the model of normal wavelets. Our results are consistent with an augmentation of SR-CaU taking place in Pcells shortly after the onset of MI. Molecular analyses done in the same MI model in pig showed that post-MI increase of SR-CaU results from the substitution of cardiac isoform SERCA2a by the ubiquitous and more potent SERCA2b in the infarcted cardiac tissues including Purkinje fibers. Our study reveals, for the first time, the molecular foundation of Purkinje arrhythmogenicity in ischemic heart and highlights novel targets for diagnosis, prevention, and treatment of risk of sudden cardiac death associated with ischemic MIs.

Ectopic Purkinje fibers recruitment leads to permanent structural and functional conductive defects following myocardial infarction in newborn mice

The Purkinje network (PN) is the most distal part of the cardiac conduction system and ensures fast conduction of the electrical impulse through the ventricles. Despite its small volume in the heart, the PN has a disproportionally high pathogenic role. Indeed, defects in PN architecture or electrophysiology trigger conduction blocks and/or ventricular arrythmia associated with poor clinical outcomes. Purkinje fibers (PF) are specialized cardiomyocytes with a low proliferative capacity and are recruited from bipotent cardiomyocyte progenitors throughout development up to the neonatal period. Late PF recruitment is dependent on maximal levels of the transcription factor Nkx2-5. A decade ago, a neonatal regenerative window was identified in mice following myocardial infarction (MI). While damaged contractile myocardium regenerates within weeks, neither PN structure nor function has been investigated in this context. This study aims to determine whether the PN is capable of regeneration in the neonatal period, and whether PN maturation is compromised in the regenerating context. Neonatal MI was performed by permanent ligation of the left coronary artery on one-day-old mice. PN structure and function were characterized by histology and electrocardiogram. PF recruitment was investigated by clonal analysis in wildtype and Nkx2-5 haploinsufficent mice. Damage caused by the MI to the PN is spatially restricted and PFs are not replaced after regeneration, leaving a gap in the network. Surprisingly, we also observed PN hyperplasia (Fig. 1A) in regions that were not directly affected by the MI, attesting to abnormal PN maturation in the context of regeneration. At the cellular level, ectopic PFs have abnormal shapes and gap junction content. Consistently, ventricular conduction was slowed, shown by an increased QRS duration (Fig. 1B). Nkx2-5± mice, which are incompetent for late PF recruitment, do not develop MI-induced hyperplasia. Together with clonal analysis, this indicates that the hyperplastic PN in WT mice arises from ectopic PF recruitment during regeneration. Our study reveals the incapacity of the PN to regenerate after direct damage. We also uncover an extended window of PF recruitment following MI, which leads to permanent structural defects and impaired electrical conduction.

Nav1-8, a new marker of Purkinje fibers, provides insight into defective conduction system maturation in a mouse model of congenital cardiomyopathy

The transcription factor Nkx2-5 is known to be a key regulator of cardiac development and NKX2-5 mutations have been found in numerous cardiac diseases associated with conduction defects. This factor is required for the differentiation of Purkinje fibers (PF), which have been implicated in triggering ventricular arrhythmias. A better understanding of the development of the Purkinje system in normal and Nkx2-5 mutant hearts could provide insight into their involvement in conduction defects in cardiac diseases. However, analysis of the Purkinje network development is hampered by the lack of specific lineage tracers. Recently, the voltage-gated sodium channel Nav1-8 short transcript has been shown to be expressed in the ventricular conduction system (VCS). This study aims to characterize the expression domain of Nav1-8 in the murine VCS to determine whether it is a suitable tool for tracing conductive cells. This would also help to identify defects in conductive recruitment in congenital disease. Nav1-8-Flp mice were crossed with a GFP reporter line for genetic tracing analyses in WT and Nkx2-5 heterozygous mice. The specificity and efficiency of Nav1-8 labelling was measured from P1 to P21 based on the number of GFP-positive (Nav1-8 derivatives), Cntn2-positive (VCS) and double positive cells (Nav1-8 derivatives in the VCS). GFP reporter expression starts at birth and is restricted to the PF at the distal part of the VCS. The specificity of Nav1-8 as a marker of PF increased over time between P1 and P21, suggesting that Nav1.8 is expressed in PF progenitor cells prior to their recruitment to the conduction system. However, its efficiency is limited to 20% of PF being marked at a mature stage of development (P21). In Nkx2-5 mutant hearts, GFP labelling within the left ventricle delimits the PF scaffold and is almost absent in the complex ramifications of the PF network. This anatomical distribution is consistent with the hypoplastic Purkinje system of these mice. However, unlike in control hearts, additional GFP+ cells are found in the bundle branches at the proximal part of the VCS in Nkx2-5 mutants. Our study shows that the sodium channel Nav1-8 represents a unique and highly specific lineage tracer of the peripheral PF in mature hearts. In addition, we show an enlargement of the Nav1-8 expression domain to the bundle branches in Nkx2-5 mutants. This indicates that Nkx2-5 may influence cell fate choice within the VCS.

Electrophysiological characterization of a 19-years-old male marathon runner suffering a sudden cardiac death

1 in 50,000 of athletes suffers a cardiac student death (SCD) per year, more of them under 35 years of age. Around 25% of these patients had normal structure, implying that other electrical disorder cause these SCD. Determine the electrophysiological causes of a SCD of a young 19-years-old occurred during a marathon with any heart structural diseases. Pathologic left ventricle (PLV) (n = 1, male, 19-years-old) and control left ventricle (CLV) (n = 1, female, 56-years-old) were perfused and imaged using high resolution optical mapping and Di-4-ANEPPS like a dye. Endocardial and endocardial free wall and his bundle were paced to obtain activation time (AT), repolarization time (RT) and action-potential duration (APD). Purkinje-muscle junctions (PMJs) were determine like activation origins far from the his bundle pacing. Effective refractory period (ERP) was determined using S1S2S3S4 short-coupled pacing. The protocol was repeated after isoplenalie injection [500 nM] like β-adrenergic receptor agonist. His-ventricle activation at high frequency pacing was higher in PLV (143ms) than in control (84ms) and decrease in both at similar levels under ISO (≈60ms). APD gradient increase was observed in PLV near PMJs under ISO (from 3ms/mm to 40ms/mm) and any gradient was observed in the control one. Ectopic episodes were observed in PLV under ISO and 82% of the origins had less that 4 mm of distance with the PMJs. In PLV, the ERP in His-pacing is always lower (320, 260, 250 ms) than endocardial (350, 315, 285 ms) pacing but in CLV, the His-pacing ERP was always higher (320, 260, 240 ms) that endocardial pacing (280, 240, 220 ms). Ventricular fibrillation (VF) was observed in PLV after his bundle pacing at high frequency (more than 330 ms) and any VF was observed in CLV. During this VF, 76% of the focal activities had less than 4 mm of distance with the PMJs. Conduction system (CS) of the PLV shows high sensitivity to high frequency pacing and to presence of ISO. Ectopic episodes and APD gradient near PMJs may show the role of Purkinje network like arrhythmic source. Indeed, the shorter ERP during His-pacing than in the endocardium, give the possibility to produce a macro-re-entry in the conduction system and maintain the arrhythmia with focal activities. CS abnormalities likely played a critical role in arrhythmogenicity and maintenance of VF in this patient during sudden cardiac death.

Moderator Band and Ventricular Tachycardia: Structural or Functional Substrate?

The moderator band (MB) is an intracavitary structure of the right ventricle composed of muscular fibers encompassing specialized Purkinje fibers, separated each other by collagen and adipose tissue. In the last decades, premature ventricular complexes originating within the Purkinje network have been implicated in the genesis of life-threatening arrhythmias. However, right Purkinje network arrhythmias have been much less reported in the literature compared to the left counterpart. The MB has unique anatomical and electrophysiological properties, which may account for its arrhythmogenicity and may be responsible for a significant portion of idiopathic ventricular fibrillation. MB embodies autonomic nervous system cells, with important implications in arrhythmogenesis. Some idiopathic ventricular arrhythmias, defined as the absence of any identifiable structural heart disorder, can begin from this site. Due to these complex structural and functional peculiarities strictly interplayed each other, it is arduous to determine the precise mechanism underlying MB arrhythmias. MB-related arrhythmias should be differentiated from other right Purkinje fibers arrhythmias because of the opportunity for intervention and the unusual site for the ablation poorly described in the literature. In the current paper, we report the characteristics and electrical properties of the MB, their involvement in arrhythmogenesis, clinical and electrophysiological peculiarities of MB-related arrhythmias, and current treatment options.

Heinrich Ewald Hering's discovery of the heart pacemaker: Hering, Tawara and Aschoff's search for its morphological basis, the sinoatrial node, and why they failed.

Two groups of investigators investigated the heart pacemaker and its morphological basis in the early twentieth century. The first group was formed by Henrich Ewald Hering (physiologist), Sunao Tawara and Ludwig Aschoff (morphologists). The second group was composed of James Mackenzie (general practitioner and clinical investigator), Arthur Keith and Martin Flack (morphologists). These groups were formed almost at the same time in 1903. Their work resulted in the discovery of the atrioventricular node and Purkinje network (Sunao Tawara, in 1906), heart pacemaker (H E Hering, in 1907) and sinoatrial node (Keith and Flack, in 1907). Here, it is shown how the interconnections of the concurrent works of these groups resulted in the discovery not only of the function, but also of the structure of the sinoatrial node.

A multi-order smoothed particle hydrodynamics method for cardiac electromechanics with the Purkinje network

In previous work, Zhang et al. (2021) developed an integrated smoothed particle hydrodynamics (SPH) method to simulate the principle aspects of cardiac function, including electrophysiology, passive and active mechanical response of the myocardium. As the inclusion of the Purkinje network in electrocardiology is recognized as fundamental to accurately describing the electrical activation in the right and left ventricles, in this paper, we present a multi-order SPH method to handle the electrical propagation through the Purkinje system and in the myocardium with monodomain/monodomain coupling strategy. We first propose an efficient algorithm for network generation on arbitrarily complex surface by exploiting level-set geometry representation and cell-linked list neighbor search algorithm. Then, a reduced-order SPH method is developed to solve the monodomain equation to characterize the fast electrical activation through the Purkinje network. Finally, a multi-order coupling paradigm is introduced to capture the coupled nature of potential propagation arising from the interaction between the network and the myocardium. A set of numerical examples are studied to assess the computational performance, accuracy and versatility of the proposed method. In particular, numerical study performed in realistic left ventricle demonstrates that the present method features all the physiological issues that characterize a heartbeat simulation, including the initiation of the signal in the Purkinje network and the systolic and diastolic phases. As expected, the results underlie the importance of using physiologically realistic Purkinje network for modeling cardiac function.

Intramural Purkinje fibers facilitate rapid ventricular activation in the equine heart.

The Purkinje fibers convey the electrical impulses at much higher speed than the working myocardial cells. Thus, the distribution of the Purkinje network is of paramount importance for the timing and coordination of ventricular activation. The Purkinje fibers are found in the subendocardium of all species of mammals, but some mammals also possess an intramural Purkinje fiber network that provides for relatively instantaneous, burst-like activation of the entire ventricular wall, and gives rise to an rS configuration in lead II of the ECG. To relate the topography of the horse heart and the distribution and histology of the conduction system to the pattern of ventricular activation as a mechanism for the unique electrical axis of the equine heart. The morphology and distribution of the cardiac conduction system was determined by histochemistry. The electrical activity was measured using ECG in the Einthoven and orthogonal configuration. The long axis of the equine heart is close to vertical. Outside the nodal regions the conduction system consisted of Purkinje fibers connected by connexin 43 and long, slender parallel running transitional cells. The Purkinje fiber network extended deep into the ventricular walls. ECGs recorded in an orthogonal configuration revealed a mean electrical axis pointing in a cranial-to-left direction indicating ventricular activation in an apex-to-base direction. The direction of the mean electrical axis in the equine heart is determined by the architecture of the intramural Purkinje network, rather than being a reflection of ventricular mass.

Myocardial development in crocodylians.

Recent reports confirmed the notion that there exists a rudimentary cardiac conduction system (CCS) in the crocodylian heart, and development of its ventricular part is linked to septation. We thus analyzed myocardial development with the emphasis on the CCS components and vascularization in two different crocodylian species. Using optical mapping and HNK-1 immunostaining, pacemaker activity was localized to the right-sided sinus venosus. The atrioventricular conduction was restricted to dorsal part of the atrioventricular canal. Within the ventricle, the impulse was propagated from base-to-apex initially by the trabeculae, later by the ventricular septum, in which strands of HNK-1 positivity were temporarily observed. Completion of ventricular septation correlated with transition of ventricular epicardial activation pattern to mature apex-to-base direction from two periapical foci. Despite a gradual thickening of the ventricular wall, no morphological differentiation of the Purkinje network was observed. Thin-walled coronary vessels with endothelium positive for QH1 obtained a smooth muscle coat after septation. Intramyocardial vessels were abundant especially in the rapidly thickening left ventricular wall. Most of the CCS components present in the homeiotherm hearts can be identified in the developing crocodylian heart, with a notable exception of the Purkinje network distinct from the trabeculae carneae.

A computational model of rabbit geometry and ECG: Optimizing ventricular activation sequence and APD distribution.

Computational modeling of electrophysiological properties of the rabbit heart is a commonly used way to enhance and/or complement findings from classic lab work on single cell or tissue levels. Yet, thus far, there was no possibility to extend the scope to include the resulting body surface potentials as a way of validation or to investigate the effect of certain pathologies. Based on CT imaging, we developed the first openly available computational geometrical model not only of the whole heart but also the complete torso of the rabbit. Additionally, we fabricated a 32-lead ECG-vest to record body surface potential signals of the aforementioned rabbit. Based on the developed geometrical model and the measured signals, we then optimized the activation sequence of the ventricles, recreating the functionality of the Purkinje network, and we investigated different apico-basal and transmural gradients in action potential duration. Optimization of the activation sequence resulted in an average root mean square error between measured and simulated signal of 0.074 mV/ms for all leads. The best-fit T-Wave, compared to measured data (0.038 mV/ms), resulted from incorporating an action potential duration gradient from base to apex with a respective shortening of 20 ms and a transmural gradient with a shortening of 15 ms from endocardium to epicardium. By making our model and measured data openly available, we hope to give other researchers the opportunity to verify their research, as well as to create the possibility to investigate the impact of electrophysiological alterations on body surface signals for translational research.

A case study: High resolution optical mapping of a 19 year old male victim of sudden cardiac death during a marathon

Fifty thousand athletes suffer sudden cardiac death every year due to ventricular fibrillation (VF). Most sudden cardiac deaths of young patients have unexplained origin due to the absence of structural or electrical disease. Purkinje network is essential for a normal heart function, however, its role during electrical pathologies remains unclear. A case study to investigate the electrophysiological properties and the Purkinje network role in a 19 years old male after suffering a fatal sudden cardiac arrest during a marathon event. A coronary-perfused left ventricular preparation was imaged using high resolution optical mapping of epicardial and endocardial surfaces using a voltage-sensitive dye, Di-4-ANEPPS. Activation time, repolarization time and action potential duration were assessed during paced activity through the His bundle and endocardial and epicardial surfaces. Conduction system activation origins were identified as distant endocardial origins during His bundle pacing. Short-coupled S1S2S3S4 pacing was used to determine effective refractory period (ERP). Pacing protocols were repeated in the presence of isoprenaline (ISO) at 100 nM, 500 nM and 1 μM to mimic stress conditions. No changes in total activation time are observed during myocardial pacing cycle lengths of 667ms in control (63ms) and under ISO (up to 64ms). In contrary, His-ventricle delay during conduction system pacing was shorted from 61ms in control to 42ms, 44ms and 16ms under 100 nM, 500 nM and 1 μM of ISO respectively. Under His pacing, local APD gradients are observed near Purkinje-muscle junctions under ISO (from 3ms/mm and 3 ms/mm to 40ms/mm and 41ms/mm). ERP under His pacing was 55ms shorter than endocardial pacing. 82% of the ectopy origins observed have less than 4 mm distance from the PMJs. Repeated focal activations were observed during VF and 76% of them had less than 4 mm distance from PMJs. No structural abnormalities were identified under 9.4 T MRI. Conduction system electrical abnormalities play a role in arrhythmogenicity and maintenance of VF in this patient during sudden cardiac death.

Role of Purkinje-muscle junction in early ventricular fibrillation in a porcine model: Beyond the trigger concept.

The role of the Purkinje network in triggering ventricular fibrillation (VF) has been studied; however, its involvement after onset and in early maintenance of VF is controversial. We studied the role of the Purkinje-muscle junctions (PMJ) on epicardial-endocardial activation gradients during early VF. In a healthy, porcine, beating-heart Langendorff model [control, n = 5; ablation, n = 5], simultaneous epicardial-endocardial dominant frequent mapping was used (224 unipolar electrograms) to calculate activation rate gradients during the onset and early phase of VF. Selective Purkinje ablation was performed using Lugol's solution, followed by VF re-induction and mapping and finally, histological evaluation. Epicardial activation rates were faster than endocardial rates for both onset and early VF. After PMJ ablation, activation rates decreased epicardially and endocardially for both onset and early VF [Epi: 9.7 ± 0.2 to 8.3 ± 0.2 Hz (p <.0001) and 10.9 ± 0.4 to 8.8 ± 0.3 Hz (p < .0001), respectively; Endo: 8.2 ± 0.3 Hz to 7.4 ± 0.2 Hz (p < .0001) and 7.0 ± 0.4 Hz to 6.6 ± 0.3 Hz (p = .0002), respectively]. In controls, epicardial-endocardial activation rate gradients during onset and early VF were 1.7 ± 0.3 Hz and 4.5 ± 0.4 Hz (p < .001), respectively. After endocardial ablation of PMJs, these gradients were reduced to 0.9 ± 0.3 Hz (onset VF, p < .001) and to 2.2 ± 0.3Hz (early VF, p <.001). Endocardial-epicardial Purkinje fiber arborization and selective Purkinje fiber extinction after only endocardial ablation (not with epicardial ablation) was confirmed on histological analysis. Beyond the trigger paradigm, PMJs determine activation rate gradients during onset and during early maintenance of VF.

Empiric ablation of polymorphic ventricular tachycardia/fibrillation in the absence of a mappable trigger: Prospective feasibility and efficacy of pacemap matching to defibrillator electrograms.

Catheter ablation strategies for ventricular fibrillation (VF) and polymorphic ventricular tachycardia (PMVT) are not established when spontaneous triggers are rare or absent. The purpose of this study was to report the feasibility and efficacy of a novel empiric ablation strategy of pacemapping to stored implantable cardioverter-defibrillator (ICD) template electrograms (SITE) of the clinical premature ventricular contraction (PVC) trigger. Fifteen patients with drug-refractory VF/PMVT receiving defibrillator shocks without identifiable and mappable PVC triggers were prospectively analyzed. The protocol incorporated systematic pacemapping from known arrhythmogenic sites (moderator band/right ventricular [RV] papillary muscles, left conduction system/Purkinje network, outflow tracts) with real-time comparison between the paced ICD electrogram (EGM) morphology and SITE. Regions within the left Purkinje network yielded the best pacemap match for the SITE of the clinical PVC trigger in 55% of ablation targets (left posterior fascicle 6, left septal fascicle 1, left anterior fascicle 5), followed by the RV moderator band region in 14% (n = 3), RV papillary muscles in 13% (n = 3), periaortic region in 14% (n = 3), and left ventricular anterolateral papillary muscle in 4% (n = 1). Freedom from ICD therapies off antiarrhythmic drug (AAD) was 64% at 6 months and 48% at 12 months. Shock burden was reduced from 4 (2-6) to 0 (0-1) (P = .001), and use of AADs was reduced from 2 (1-2) to 0 (0-1) (P = .001). In the absence of a mappable trigger, an empiric strategy of interrogating the Purkinje network, papillary muscles, and outflow tract regions by pacemap matching with SITE of the clinical PVC is feasible to guide ablation. A significant reduction in VF/PMVT therapy burden and AAD utilization was observed after a single procedure.

A fast computational model for the electrophysiology of the whole human heart

In this study we present a novel computational model for unprecedented simulations of the whole cardiac electrophysiology. According to the heterogeneous electrophysiologic properties of the heart, the whole cardiac geometry is decomposed into a set of coupled conductive media having different topology and electrical conductivities: (i) a network of slender bundles comprising a fast conduction atrial network, the AV–node and the ventricular bundles; (ii) the Purkinje network; and (iii) the atrial and ventricular myocardium. The propagation of the action potential in these conductive media is governed by the bidomain/monodomain equations, which are discretized in space using an in–house finite volume method and coupled to three different cell models, the Courtemanche model [1] for the atrial myocytes, the Stewart model [2] for the Purkinje Network and the ten Tusscher–Panfilov model [3] for the ventricular myocytes. The developed numerical model correctly reproduces the cardiac electrophysiology of the whole human heart in healthy and pathologic conditions and it can be tailored to study and optimize resynchronization therapies or invasive surgical procedures. Importantly, the whole solver is GPU–accelerated using CUDA Fortran providing an unprecedented speedup, thus opening the way for systematic parametric studies and uncertainty quantification analyses.

Purkinje network and myocardial substrate at the onset of human ventricular fibrillation: implications for catheter ablation.

AimsMapping data of human ventricular fibrillation (VF) are limited. We performed detailed mapping of the activities underlying the onset of VF and targeted ablation in patients with structural cardiac abnormalities.Methods and resultsWe evaluated 54 patients (50 ± 16 years) with VF in the setting of ischaemic (n = 15), hypertrophic (n = 8) or dilated cardiomyopathy (n = 12), or Brugada syndrome (n = 19). Ventricular fibrillation was mapped using body-surface mapping to identify driver (reentrant and focal) areas and invasive Purkinje mapping. Purkinje drivers were defined as Purkinje activities faster than the local ventricular rate. Structural substrate was delineated by electrogram criteria and by imaging. Catheter ablation was performed in 41 patients with recurrent VF. Sixty-one episodes of spontaneous (n = 10) or induced (n = 51) VF were mapped. Ventricular fibrillation was organized for the initial 5.0 ± 3.4 s, exhibiting large wavefronts with similar cycle lengths (CLs) across both ventricles (197 ± 23 vs. 196 ± 22 ms, P = 0.9). Most drivers (81%) originated from areas associated with the structural substrate. The Purkinje system was implicated as a trigger or driver in 43% of patients with cardiomyopathy. The transition to disorganized VF was associated with the acceleration of initial reentrant activities (CL shortening from 187 ± 17 to 175 ± 20 ms, P < 0.001), then spatial dissemination of drivers. Purkinje and substrate ablation resulted in the reduction of VF recurrences from a pre-procedural median of seven episodes [interquartile range (IQR) 4–16] to 0 episode (IQR 0–2) (P < 0.001) at 56 ± 30 months.ConclusionsThe onset of human VF is sustained by activities originating from Purkinje and structural substrate, before spreading throughout the ventricles to establish disorganized VF. Targeted ablation results in effective reduction of VF burden.Key questionThe initial phase of human ventricular fibrillation (VF) is critical as it involves the primary activities leading to sustained VF and arrhythmic sudden death. The origin of such activities is unknown.Key findingBody-surface mapping shows that most drivers (≈80%) during the initial VF phase originate from electrophysiologically defined structural substrates. Repetitive Purkinje activities can be elicited by programmed stimulation and are implicated as drivers in 37% of cardiomyopathy patients.Take-home messageThe onset of human VF is mostly associated with activities from the Purkinje network and structural substrate, before spreading throughout the ventricles to establish sustained VF. Targeted ablation reduces or eliminates VF recurrence.