Transmural Dispersion Of Refractoriness Research Articles

Analysis of unipolar electrograms in rabbit heart demonstrated the key role of ventricular apicobasal dispersion in arrhythmogenicity.

Reduced repolarization reserve and increased transmural dispersion of repolarization (TDR) are known risk factors for Torsade de Pointes development, but less is known about the role of apex-to-base (apicobasal) repolarization in arrhythmogenesis. Three needles were inserted in rabbit left ventricle to record unipolar electrograms from endocardium to epicardium and base to apex. Total repolarization interval (TRI) and peak-to-end repolarization interval (Tp) were assessed after quinidine (n=6) and D,L-sotalol (n=6) perfusion in combination with the IKs inhibitor chromanol 293B. About 30µM D,L-sotalol increased TRI and Tp more at the base (TRI +40±4%; Tp +89±11%) relative to the apex (TRI +28±3%, Tp +30±8%). Similar results were obtained with quinidine: TRI and Tp increased more at the base compared to the apex. No significant differences were recorded from the endocardium to the epicardium. Our results show that combined IKr+IKs block prolonged TRI and Tp significantly more at the ventricular base than at the apex, in the absence of transmural dispersion of refractoriness. Regional changes in TRI and Tp indicate the contribution of apicobasal dispersion to arrhythmogenicity compared to TDR in a rabbit heart model.

Dofetilide Promotes Repolarization Abnormalities in Perfused Guinea-pig Heart

Dofetilide is class III antiarrhythmic agent which prolongs cardiac action potential duration because of selective inhibition of I (Kr), the rapid component of the delayed rectifier K(+) current. Although clinical studies reported on proarrhythmic risk associated with dofetilide treatment, the contributing electrophysiological mechanisms remain poorly understood. This study was designed to determine if dofetilide-induced proarrhythmia may be attributed to abnormalities in ventricular repolarization and refractoriness. The monophasic action potential duration and effective refractory periods (ERP) were assessed at distinct epicardial and endocardial sites along with volume-conducted ECG recordings in isolated, perfused guinea-pig heart preparations. Dofetilide was found to produce the reverse rate-dependent prolongation of ventricular repolarization, increased the steepness of action potential duration rate adaptation, and amplified transepicardial variability in electrical restitution kinetics. Dofetilide also prolonged the T peak-to-end interval on ECG, and elicited a greater prolongation of endocardial than epicardial ERP, thereby increasing transmural dispersion of refractoriness. At epicardium, dofetilide prolonged action potential duration to a greater extent than ERP, thus extending the critical interval for ventricular re-excitation. This change was associated with triangulation of epicardial action potential because of greater dofetilide-induced prolonging effect at 90 % than 30 % repolarization. Premature ectopic beats and spontaneous short-lasting episodes of monomorphic ventricular tachycardia were observed in 44 % of dofetilide-treated heart preparations. Proarrhythmic potential of dofetilide in guinea-pig heart is attributed to steepened electrical restitution, increased transepicardial variability in electrical restitution kinetics, amplified transmural dispersion of refractoriness, increased critical interval for ventricular re-excitation, and triangulation of epicardial action potential.

Impact of Na+ channel blockers on transmural dispersion of refractoriness and arrhythmic susceptibility in guinea-pig left ventricle

Clinically, class Ib antiarrhythmic agents (selective INa blockers) are considered to be safe drugs, whereas class Ia and Ic agents (non-selective blockers of both INa and IKr, the rapid component of the delayed rectifier) may evoke proarrhythmia. I hypothesized that this difference is accounted for by differential drug effects on transmural dispersion of refractoriness, in the presence of the reciprocal distribution profile of INa and IKr across ventricular wall, as determined in previous studies. Specifically, less epicardial than endocardial INa reserve would likely contribute to a greater prolongation of the effective refractory period (ERP) at epicardium by the INa blocker, thereby reducing epicardial-to-endocardial ERP dispersion, with resulting antiarrhythmic effect. In contrast, less endocardial than epicardial IKr reserve would likely contribute to a greater prolongation of repolarization at the endocardium by the IKr blocker, thereby amplifying transmural ERP dispersion and inducing arrhythmia. In perfused guinea-pig hearts, dofetilide, a specific IKr blocker, as well as class Ia (quinidine, procainamide) and class Ic agents (flecainide), were found to prolong the QT interval and monophasic action potential duration, and elicited greater endocardial than epicardial ERP prolongation, thus markedly increasing transmural ERP dispersion. These changes were associated with episodes of monomorphic ventricular tachycardia in 30–40% of experiments. In contrast, class Ib agents (lidocaine, mexiletine) evoked greater epicardial than endocardial ERP lengthening, thereby decreasing transmural ERP dispersion, and produced no tachyarrhythmia. These findings suggest that transmural ERP dispersion is the electrophysiological determinant which may shape the profile of class I agent effects on arrhythmic susceptibility.

Role of K ATP Channels in the Maintenance of Ventricular Fibrillation in Cardiomyopathic Human Hearts

Ventricular fibrillation (VF) leads to global ischemia. The modulation of ischemia-dependent pathways may alter the electrophysiological evolution of VF. We addressed the hypotheses that there is regional disease-related expression of K(ATP) channels in human cardiomyopathic hearts and that K(ATP) channel blockade promotes spontaneous VF termination by attenuating spatiotemporal dispersion of refractoriness. In a human Langendorff model, electric mapping of 6 control and 9 treatment (10 μmol/L glibenclamide) isolated cardiomyopathic hearts was performed. Spontaneous defibrillation was studied and mean VF cycle length was compared regionally at VF onset and after 180 seconds between control and treatment groups. K(ATP) subunit gene expression was compared between LV endocardium versus epicardium in myopathic hearts. Spontaneous VF termination occurred in 1 of 6 control hearts and 7 of 8 glibenclamide-treated hearts (P=0.026). After 180 seconds of ischemia, a transmural dispersion in VF cycle length was observed between epicardium and endocardium (P=0.001), which was attenuated by glibenclamide. There was greater gene expression of all K(ATP) subunit on the endocardium compared with the epicardium (P<0.02). In an ischemic rat heart model, transmural dispersion of refractoriness (ΔERP(Transmural)=ERP(Epicardium)-ERP(Endocardium)) was verified with pacing protocols. ΔERP(Transmural) in control was 5 ± 2 ms and increased to 36 ± 5 ms with ischemia. This effect was greatly attenuated by glibenclamide (ΔERP(Transmural) for glibenclamide+ischemia=4.9 ± 4 ms, P=0.019 versus control ischemia). K(ATP) channel subunit gene expression is heterogeneously altered in the cardiomyopathic human heart. Blockade of K(ATP) channels promotes spontaneous defibrillation in cardiomyopathic human hearts by attenuating the ischemia-dependent spatiotemporal heterogeneity of refractoriness during early VF.

RT, RTend and Tpeak-End Intervalby Signal-Averaged Vector 187 Channel High Resolution ECG for Risk Stratification of Brugada Syndrome

Spatial and transmural dispersion of refractoriness have been reported to relate to arrhythmogenesis of Brugada syndrome (BS). Recovery time (RT), RTend and Tpeak-end (Tp-e) was evaluated in Brugada syndrome (BS). The synthesized signals from vector-projected 187-channel ECGs were amplified. Maximum inter-lead difference, mean inter-lead difference of RT, max. and avg. RT, max. and avg. RTend, max. and avg. Tp-e interval, and late potential by vector magnitude ECG were compared were studied in 27 spontaneous type 1 ECG and 14 non-type 1 BS patients. There were no significant differences in max. and avg. RTend interval, max. Tp-e interval, and avg. RT between type 1 and non-type 1 patients. But max. RT was marginally longer in type 1 patients (86.3±20.8 vs. 73.7±20.9 ms, P=0.07). No relation was found between max. and avg. RT and RTend, and max. Tpeak-end to the symptom. However, avg. Tp-e interval was significantly longer in patients with than that in patients without symptom (41.1±15.2 ms vs. 27.6±13.7 ms, P=0.028). Late potentials were positive in 87.5% (7/8) in 8 patients with symptom, and in 50% (16/32) in patients without symptom P=0.1074). Conclusions: Spatial dispersion of repolarization may relate to the typical ECG manifestation of BS and not spatial and transmural dispersion of repolarization but conduction disturbance may relate to the arrhythmic events.

A sympathetic model of L-type Ca2+ channel-triggered arrhythmias

A sympathetic model of L-type Ca²⁺ channel-triggered arrhythmias

Loss of Intracellular and Intercellular Synchrony of Calcium Release in Systolic Heart Failure

Normal contraction of cardiac muscle requires a coordinated cellular mechanical response to the electric pacemaker signal that begins in the sinoatrial node and spreads through the conduction system and ultimately across the ventricular myocardium via gap junctions. In ventricular myocytes, depolarization by the action potential causes clusters of L-type calcium channels (LCCs) to open, allowing a small amount of Ca to enter the diadic cleft space between the sarcolemma and the sarcoplasmic reticulum (SR). When the Ca concentration in this space becomes sufficiently high to gate ryanodine receptors (RyRs), they open and release SR Ca into the cytoplasm, so that it can bind to and activate myofilaments, resulting in force development. Each cluster of LCCs on the sarcolemma, its opposing cluster of RyRs across the 10- to 12-nm diameter diadic cleft space, and associated SR regulatory proteins is a couplon.1 According to the local control theory of cardiac excitation-contraction (EC) coupling, couplons are activated independently. Independent activation of couplons depends on the extent of LCC activation, providing a mechanism for regulation of contractile force by stochastic recruitment of couplons.2 In systolic heart failure, numerous cellular defects in EC coupling and Ca regulation have been identified that contribute to contractile dysfunction (and ventricular arrhythmias), although there is a host of other major abnormalities leading to loss of force development, including fibrosis,3 defective energy metabolism,4 pH changes,5 heterogeneous conductance across connexin hemichannels,6 and defects in sarcomeric proteins.7 Thus, it is important to keep in mind that no single defect can explain the contractile dysfunction of systolic failure. Article see p 223 Recent studies of defective EC coupling in heart failure have addressed not only reductions in the extent and kinetics of Ca released in response to the action potential (ie, reduced recruitment of couplons and …

Transmural dispersion of refractoriness and conduction velocity is associated with heterogeneously reduced connexin43 in a rabbit model of heart failure

Heterogeneity of repolarization and conduction is a potential source of arrhythmogenesis. In heart failure (HF), intercellular coupling is reduced and heterogeneities may become evident because of reduced intercellular coupling. This study sought to investigate connexin43 (Cx43) expression, conduction velocity (CV), refractoriness and inducibility of arrhythmias at multiple sites of the left ventricle during HF. HF was induced by pressure-volume overload in rabbits. Epicardial and intramural mapping was performed in isolated perfused hearts following programmed stimulation. Myocytes were enzymatically dissociated and studied using D-4-ANEPPS fluorescence. Western blotting and immunohistochemistry was performed to quantify heterogeneity of Cx43 expression. Cx43 was heterogeneously reduced in the midmyocardial, but not in the sub epicardium layer of the left ventricular free wall in HF compared to control rabbits. In HF, subepicardial and midmyocardial refractory periods (RPs) were increased compared to control rabbits (148 +/- 3 ms and 143 +/- 3 versus 131 +/- 2 and 129 +/- 2 ms, respectively, both P < 0.001). Also, transmural dispersion of RPs was larger in HF (30 +/- 4 ms) than in control rabbits (24 +/- 3 ms, P < 0.05). Intrinsic dispersion of action potential duration in isolated myocytes was similar in HF and control rabbits. Transmural CV was heterogeneous, although the mean CV was not different between groups. Arrhythmias were more easily inducible in HF, especially from midmyocardium. In HF, midmyocardial Cx43 expression is heterogeneously reduced. This is associated with increased transmural dispersion in refractoriness and conduction, and with increased arrhythmia inducibility.

Effects of the I(Kr)-blocking agent dofetilide and of the I(Ks)-blocking agent chromanol 293b on regional disparity of left ventricular repolarization in the intact canine heart.

Recent in vitro studies have described regional differences of ion current expression and function, possibly accounting for reduced homogeneity of repolarization in the heart. In 11 intact canine hearts regional disparity of repolarization was determined at baseline and after administration of the I(Kr) blocking agent dofetilide (30 microg/kg) and the I(Ks)-blocking agent chromanol 293b (10 mg/kg). Effective refractory periods (ERPs) were determined through up to 10 needle electrodes inserted into basal, midwall and apical regions of the left ventricular wall using the extrastimulus technique (cycle length [CL] 300 and 850 ms). At baseline (CL of 850 ms), ERPs were significantly longer in epicardial muscle layers of the apex compared to the base. In deeper muscle layers regional differences of ERPs were not detectable. Administration of dofetilide increased apico-basal disparity of repolarization, due to a more marked increase of ERPs in the apex than in the base. In contrast, homogeneous ERPs were evident along the apico-basal axis after administration of chromanol 293b. Transmural dispersion of refractoriness could not be observed in any region at baseline, or after drug-administration. In the intact canine heart, apico-basal disparity of repolarization varies between individual muscle layers. Dependent on their current specificity, antiarrhythmic agents may enhance or diminish regional disparity of repolarization.