Electrogramas auriculares endocárdicos anormales en pacientes de la tercera edad con fibrilación auricular paroxística idiopática / Abnormal atrial endocardial electrograms in aging patients with idiopathic paroxysmal atrial fibrillation

Los pacientes de la tercera edad están particularmente predispuestos a desarrollar episodios de fibrilación auricular paroxística (FAP), pudiendo ser los cambios que experimenta el miocardio auricular un factor contribuyente a la aparición de este fenómeno con el correr de los años. Por ende, diseñamos este trabajo con la idea de investigar los cambios que se producen en los electrogramas auriculares endocárdicos registrados por medio de un mapeo intraauricular con catéter en pacientes con FAP idiopática en la tercera edad. Realizamos un mapeo endocárdico con catéter de la aurícula derecha en ritmo sinusal en 72 pacientes con FAP idiopática para evaluar la influencia de la edad avanzada en los electrogramas auriculares endocárdicos. Los electrogramas bipolares fueron registrados de 12 sitios de la aurícula derecha, y un electrograma endocárdico auricular anormal fue definido como aquel que posee una duración ≥100 ms, y/o 8 o más deflexiones fragmentadas. Se registraron 864 electrogramas auriculares endocárdicos que fueron analizados cuantitativamente. El número de electrogramas auriculares anormales, así como la máxima duración y el mayor número de deflexiones fragmentadas de los electrogramas auriculares endocárdicos en los pacientes con FAP idiopática tuvo una correlación significativamente positiva con la edad. Se observó que la edad avanzada altera las propiedades electrofisiológicas del miocardio auricular haciéndolo más susceptible a desarrollar episodios de FAP. Estos cambios electrofisiológicos son más extensos conforme aumenta la edad. Existe un aumento progresivo en la extensión de la anormalidad electrofisiológica del miocardio auricular en pacientes de la tercera edad con fibrilación auricular paroxística idiopática.

There is a predisposition to develop paroxysmal atrial fibrillation (PAF) in aging patients,and theatrial musclechangesdue to the aging process could be a contributing factortothedevelopment of this tachyarrhythmia.Thus, we designedthis study to investigate thechangesobserved in the recorded atrial endocardial electrograms by means of an intra-atrial catheter mapping inpatients withidiopathicPAF. We performed an endocardialmapping of the right atrium in 72patientswith idiopathic PAFduring sinus rhythm toevaluate the influence of advancing age on the atrial endocardial electrograms. The bipolarelectrograms were recorded at 12 sites of the right atrium and an abnormal atrialelectrogram was defined as having a duration≥100 ms, and/or eight or more fragmenteddeflections.We recorded 864 atrial endocardial electrograms that were quantitativelyanalyzed. The number of abnormalatrial electrograms, as well asthe wider duration andthe greater number of fragmented deflections of the atrial endocardial electrograms,showed a significantpositive correlation with agingin patients with idiopathic PAF.It wasobserved that aging alters the electrophysiological properties of the atrial muscleincreasing the susceptibility to develop episodes of PAF. These electrophysiologicalchanges aremore extensivein advancing age. There is a progressive increase in theextension of the electrophysiologically altered atrial muscle in aging patients withidiopathicPAF.

The right ventricular outflow tract as an unusual location for an implantable defibrillator electrode in a patient with arrhythmogenic right ventricular dysplasia.

A 41-year-old woman with arrhythmogenic right ventricular dysplasia (ARVD) underwent the implantation of an implantable cardioverter-defibrillator (ICD), in which the defibrillator electrode was unusually located in the right ventricular (RV) outflow tract. Although fractionated electrograms were demonstrated in the RV apex, which is the usual site for ICD electrodes, normal electrograms were recorded in the RV outflow tract during an electrophysiologic study. An electrode with a screw-in tip was used to fix the implant in the RV outflow tract and obtain successful defibrillation. If normal electrograms are recorded in the RV outflow tract, the site may prove to be an alternative location for an ICD electrode even for ARVD patients.

Double ventricular response via dual atrioventricular nodal pathways resulting with nonreentrant supraventricular tachycardia and successfully treated with radiofrequency catheter ablation.

We report a patient with a complex nonreentrant supraventricular tachycardia because of double ventricular response resulting from antegrade dual atrioventricular (AV) nodal pathways. We could induce double ventricular response and confirm dual AV nodal pathways by AV simultaneous pacing during basic stimulation proceeding with programmed atrial single extrastimulation. As far as we know, it is the first report about the application of the AV simultaneous basic stimulation to prove the sustained nonreentrant tachycardia because of simultaneous conduction over dual AV nodal pathways. This was also confirmed by absence of the arrhythmia immediately after the elimination of the slow pathway conduction by radiofrequency ablation.

[Dietary intake of trace elements in the general population, estimated from a regional nutritional survey, and comparison with recommended dietary allowances and tolerable upper intake levels].

OBJECTIVES: Dietary intake by the general population of trace elements related to human health is not well known. Therefore, values for zinc, copper, manganese, chromium, selenium, molybdenum, cobalt and aluminum were estimated from food intake data from the 1993 Tottori Prefecture Nutritional Survey. For each element, consumption by the individual person was compared to the recommended dietary allowance (RDA) and the tolerable upper intake level (UL). METHODS: Daily intake of trace elements by individuals was calculated from food intake data of 1993 Tottori Prefecture Nutrition Survey by computer program written by visual C++ using the trace element food table published by Suzuki (1993) and compared with RDA and UL values. RESULTS: 1. The percentage of people whose intake of zinc was lower than the RDA was 72.0%. Those for copper and manganese were 69.8% and 39.2%, respectively. Persons aged over 60 years consumed less of those trace elements. 2. Few people had a chromium intake lower than the RDA. The same was the case for molybdenum and selenium. However, 9.2% of people had on intake of chromium in excess of the UL, and for manganese, molybdenum and selenium the figures were 0.7%, 81.6% and 9.6%, respectively. 3. The major sources of the trace elements were cereals, fish, meats, vegetables and beans. CONCLUSIONS: It is necessary to investigate the reason for the low intake of zinc, copper and manganese. It is also to be recommended that food tables for trace elements be produced to feel compliance with the RDA and UL for trace elements.

Radiofrequency catheter ablation of a concealed atrioventricular accessory pathway associated with a coronary sinus diverticulum.

A 31-year-old woman underwent radiofrequency catheter ablation of a concealed left posteroseptal accessory pathway associated with a coronary sinus diverticulum. The patient had previously undergone unsuccessful catheter ablation of the posteroseptal region of the mitral annulus. Coronary sinus venography revealed the presence of the diverticulum near the ostium. An electrogram in the neck of the diverticulum showed the shortest ventriculoatrial conduction time and a large accessory pathway potential during atrioventricular reciprocating tachycardia. The pathway was successfully ablated within the neck of the diverticulum. The findings in this case underscore the importance of coronary sinus venography before ablation.

SUR2 subtype (A and B)-dependent differential activation of the cloned ATP-sensitive K+ channels by pinacidil and nicorandil.

1. The classical ATP sensitive K+ (K(ATP)) channels are composed of a sulphonylurea receptor (SUR) and an inward rectifying K+ channel subunit (BIR/Kir6.2). They are the targets of vasorelaxant agents called K+ channel openers, such as pinacidil and nicorandil. 2. In order to examine the tissue selectivity of pinacidil and nicorandil, in vitro, we compared the effects of these agents on cardiac type (SUR2A/Kir6.2) and vascular smooth muscle type (SUR2B/Kir6.2) of the K(ATP) channels heterologously expressed in HEK293T cells, a human embryonic kidney cell line, by using the patch-clamp method. 3. In the cell-attached recordings (145 mM K+ in the pipette), pinacidil and nicorandil activated a weakly inwardly-rectifying, glibenclamide-sensitive 80 pS K+ channel in both the transfected cells. 4. In the whole-cell configuration, pinacidil showed a similar potency in activating the SUR2B/Kir6.2 and SUR2A/Kir6.2 channels (EC50 of approximately 2 and approximately 10 microM, respectively). On the other hand, nicorandil activated the SUR2B/Kir6.2 channel > 100 times more potently than the SUR2A/Kir6.2 (EC50 of approximately 10 microM and > 500 microM, respectively). 5. Thus, nicorandil, but not pinacidil, preferentially activates the K(ATP) channels containing SUR2B. Because SUR2A and SUR2B are diverse only in 42 amino acids at their C-terminal ends, it is strongly suggested that this short part of SUR2B may play a critical role in the action of nicorandil on the vascular type classical K(ATP) channel.

The effects of nucleotides and potassium channel openers on the SUR2A/Kir6.2 complex K+ channel expressed in a mammalian cell line, HEK293T cells.

The effects of potassium channel opening drugs and intracellular nucleotides on the ATP-sensitive K+ (KATP) channel composed of SUR2A and Kir6.2 in HEK293T cells were examined using the patch-clamp technique. The SUR2A/Kir6.2 channel was activated effectively by pinacidil, marginally by nicorandil but not by diazoxide. The pinacidil-activated channel currents were inhibited by glibenclamide with a Ki value of 160 nM. Upon formation of inside-out (I-O) patches, spontaneous openings of the channels appeared, which were inhibited by intracellular ATP (ATPi) equipotently in the presence and in the absence of intracellular Mg2+ (Mg2+i). The channel activity ran-down gradually in I-O patches. The run-down channels could be reactivated by ATPi only in the presence of Mg2+i. Uridine 5'-diphosphate (UDP) antagonized the ATPi-mediated inhibition of the channel activity before run-down. After run-down, UDP activated the channel without antagonizing ATPi-mediated channel inhibition. Thus, the SUR2A/Kir6.2 reproduced the major properties of the native cardiac KATP channel well in terms of nucleotide regulation and pharmacology, and therefore can be a useful tool with which to elucidate the molecular mechanisms characterizing the KATP channel.

Cloning and tissue distribution of novel splice variants of the rat GABAB receptor.

We have identified two novel splice variants of the metabotropic gamma-aminobutyric acid receptor (GABABR1), designated GABABR1c and GABABR1d, when screening a rat cerebellum cDNA library. GABABR1c has an amino acid sequence identical to GABABR1b, a member of GABABR1 isoforms, and an additional 93-bp insertion that generates an additional 31-amino-acid sequence in the fifth transmembrane region of GABABR1b. Thus, GABABR1c may have a structural variation in the second extracellular loop and fifth transmembrane region. GABABR1d also has an amino acid sequence identical to GABABR1b and an additional insertion of 566 bp that generates a divergent amino acid sequence in the carboxylterminal end. Reverse-transcription polymerase chain reaction analysis showed that in various rat tissues GABABR1c mRNA was ubiquitously expressed and GABABR1d mRNA in forebrain, cerebellum, eye, kidney, and urinary bladder. GABABR1 isoforms may function not only in the central nervous system but also in various peripheral tissues.

Sulphonylurea receptor 2B and Kir6.1 form a sulphonylurea-sensitive but ATP-insensitive K+ channel.

1. We analysed the K+ channel composed of the sulphonylurea receptor 2B (SUR2B) and an inwardly rectifying K+ channel subunit Kir6.1 coexpressed in a mammalian cell line, HEK293T, with the patch clamp technique. 2. In the cell-attached configuration, K+ channel openers (pinacidil and nicorandil) activated approximately 33 pS K+ channels (approximately 145 mM external K+), which were inhibited by the sulphonylurea glibenclamide. 3. Although SUR2B forms an ATP-sensitive K+ channel with Kir6.2, whose amino acid sequence is approximately 70% homologous with that of Kir6.1, the K+ channel composed of SUR2B and Kir6.1 surprisingly did not spontaneously open on patch excision in the absence of intracellular ATP. 4. In inside-out patches, uridine diphosphate and guanosine diphosphate induced channel activity, which was inhibited by glibenclamide but not ATP. Intracellular ATP on its own activated the channels. K+ channel openers and intracellular nucleotides synergistically activated the channel. 5. Therefore, the K+ channel composed of SUR2B and Kir6.1 is not a classical ATP-sensitive K+ channel but closely resembles the nucleotide diphosphate-dependent K+ channel in vascular smooth muscle cells.

Inwardly rectifying potassium channels: their molecular heterogeneity and function.

A variety of cells including cardiac myocytes and neuronal cells possess inwardly rectifying K+ (Kir) channels through which currents flow more readily in the inward direction than outward. These K+ channels play pivotal roles in maintenance of the resting membrane potential, in regulation of the action potential duration, in receptor-dependent inhibition of cellular excitability, and in the secretion and absorption of K+ ions across cell membrane. Recent molecular biological dissection has shown that the DNAs encoding Kir channels constitute a new family of K+ channels whose subunits contain two putative transmembrane domains and a pore-forming region. So far, more than ten cDNAs of Kir channel subunits have been isolated and classified into four subfamilies: 1) IRK subfamily (IRK1-3/Kir1.1-1.3), 2) GIRK subfamily (GIRK1-4/Kir3.1-3.4), 3) ATP-dependent Kir subfamily (ROMK1/Kir1.1, K(AB)-2/Kir4.1), and 4) ATP-sensitive Kir subfamily (uKATP-1/Kir6.1, BIR/Kir6.2). Xenopus oocytes injected with the cRNAs of IRKs elicit classical Kir channel currents. GIRKs, as heteromultimers, compose the G protein-gated Kir (KG) channels, which are regulated by a variety of Gi/Go-coupled inhibitory neurotransmitter receptors such as m2-mus-carinic, serotonergic (5HT1A), GABAB, somatostatin and opioid (mu, delta, kappa) receptors. ROMK1 and KAB-2 are characterized with a Walker type-A ATP-binding motif in their carboxyl termini, and may be involved in K+ transport in renal epithelial and brain glial cells. uKATP-1 and BIR form with sulfonylurea receptors, the so-called ATP-sensitive K+ channels. Thus, it is a feature of the Kir channel family that each subfamily plays a specific physiological functional role. The (Na+)-activated Kir channels identified electrophysiologically in neurons and cardiac myocytes have not yet been cloned. In this review, we overviewed the current understandings of the features of the molecular structures and functions of the four main subfamilies of Kir channels.

Unmasking of fast and slow atrioventricular nodal pathways by successful radiofrequency ablation of two accessory atrioventricular connections.

Electrophysiologic findings suggesting the coexistence of dual atrioventricular (AV) nodal pathways and accessory AV connections have been previously described. Anterograde conduction through the accessory pathway (AP) may preclude the diagnosis of AV nodal dual pathway physiology during atrial stimulation. This study reports on a patient with manifest Wolff-Parkinson-White syndrome with clinically documented paroxysmal atrial fibrillation, in whom dual AV nodal pathways were unmasked after successful radiofrequency ablation of two accessory AV connections. In spite of detailed investigation, fast and slow AV nodal pathways were not detected in the first electrophysiologic study 8 years before ablation, nor were they detected during preablation study because of exclusive anomalous anterograde conduction. The anterograde AP effective refractory period was shorter than that of the fast and slow AV nodal pathways, and was limited by atrial refractoriness at 190 ms. The present findings strongly suggest the necessity for a careful postablation eletrophysiologic study before and after isoproterenol administration with specific evaluation of AV nodal conduction. This is the first documented report on the finding of AV nodal dual pathway physiology and reentry after successful radiofrequency ablation of two APs. This finding may be of great therapeutic significance in light of the feasibility of slow pathway ablation also during a single session, had AV nodal reentry been induced in a sustained manner after ablation of the AP to prevent late recurrence of tachycardia.

Function, regulation, pharmacology, and molecular structure of ATP-sensitive K+ channels in the cardiovascular system.

ATP-sensitive K+ (K[ATP]) channels are inhibited by intracellular ATP and activated by intracellular nucleoside diphosphates, and thus provide a link between cellular metabolism and excitability. K(ATP) channels are widely distributed in various tissues and may be associated with diverse cellular functions. In the heart, the K(ATP) channel appears to be activated during ischemic or hypoxic conditions and may be responsible for the increase of K+ efflux and shortening of the action potential duration. Therefore, opening of this channel may result in cardioprotective as well as proarrhythmic effects. In the vascular smooth muscle, the K(ATP) channel is believed to mediate the relaxation of vascular tone. Thus, K(ATP) channels play important regulatory roles in the cardiovascular system. Furthermore, K(ATP) channels are the targets of two important classes of drugs, i.e., the antidiabetic sulfonylureas, which block the channels, and a series of vasorelaxants called "K+ channel openers," which tend to maintain the channels in an open conformation. Recently, the molecular structure of K(ATP) channels has been clarified. The K(ATP) channel in pancreatic beta-cells is a complex composed of at least two subunits, a member of inwardly rectifying K+ channels and a sulfonylurea receptor. Subsequently, two additional homologs of the sulfonylurea receptor, which form cardiac and smooth muscle type K(ATP) channels, respectively, have been reported. Further works are now in progress to understand the molecular mechanisms of K(ATP) channel function.

Cloning and functional expression of a novel isoform of ROMK inwardly rectifying ATP-dependent K+ channel, ROMK6 (Kir1.1f).

We have identified from rat kidney a novel isoform of ROMK/Kir1.1, designated ROMK6/Kir1.1f. ROMK6 was nearly identical to ROMK1, but possessed an 122-bp insertion in the 5' region. Its deduced amino acid sequence was shorter by 19 amino acids than that of ROMK1 in the amino-terminus. Unlike other previously reported ROMK isoforms, ROMK6 mRNA was ubiquitously expressed in various tissues, including kidney, brain, heart, liver, pancreas and skeletal muscle. Xenopus oocytes injected with ROMK6 cRNA expressed a Ba2+-sensitive weakly inwardly rectifying K+ current. These results indicate that ROMK6 is a novel functional K+ channel and might be involved in K+ secretion in various tissue.

A novel sulfonylurea receptor forms with BIR (Kir6.2) a smooth muscle type ATP-sensitive K+ channel.

We have isolated a cDNA encoding a novel isoform of the sulfonylurea receptor from a mouse heart cDNA library. Coexpression of this isoform and BIR (Kir6.2) in a mammalian cell line elicited ATP-sensitive K+ (KATP) channel currents. The channel was effectively activated by both diazoxide and pinacidil, which is the feature of smooth muscle KATP channels. Sequence analysis indicated that this clone is a variant of cardiac type sulfonylurea receptor (SUR2). The 42 amino acid residues located in the carboxyl-terminal end of this novel sulfonylurea receptor is, however, divergent from that of SUR2 but highly homologous to that of the pancreatic one (SUR1). Therefore, this short part of the carboxyl terminus may be important for diazoxide activation of KATP channels. The reverse transcription-polymerase chain reaction analysis showed that mRNA of this clone was ubiquitously expressed in diverse tissues, including brain, heart, liver, urinary bladder, and skeletal muscle. These results suggest that this novel isoform of sulfonylurea receptor is a subunit reconstituting the smooth muscle KATP channel.

[Molecular structure and expression of ion channels in the heart].

Ion channels are essential for the generation and maintenance of the cardiac action potential. The successful cloning of ion channels has shed considerable light into their structure and function. The combination of molecular biological and electrophysiological studies has paved the ground to develop general concepts for understanding properties of these channels, such as gating mechanism, kinetics of activation and inactivation, ion selectivity and pharmacological properties. Recently, several cDNAs encoding cardiac inwardly rectifying K+ channels, including classical inwardly rectifying, G-protein-gated, and ATP-sensitive K+ channels, have been isolated. Identification of these molecular mechanisms may point to novel approaches to the treatment of cardiac arrhythmias. This review focuses on the molecular properties and functional roles of cardiac ion channels.

Immunolocalization of an inwardly rectifying K+ channel, K(AB)-2 (Kir4.1), in the basolateral membrane of renal distal tubular epithelia.

Immunolocalization of K(AB)-2 (Kir4.1), an inwardly rectifying K+ channel with a putative ATP-binding domain, was examined in rat kidney where expression of K(AB)-2 mRNA was previously shown. Anti-K(AB)-2 antibody was raised in rabbit and then affinity-purified. An immunohistochemical study revealed that K(AB)-2 immunoreactivity was detected specifically in the basolateral membrane of distal tubular epithelia. Therefore, K(AB)-2 is the first K+ channel shown to be localized in the basolateral membrane of renal epithelia. The finding suggests that K(AB)-2 may contribute to supplying K+ to the Na(+)-K+ pump, which is abundant in the basolateral membrane of distal tubular epithelia, as well as to maintenance of the deep negative membrane potential of these cells.

[Molecular and biophysical aspects of potassium channels].

K+ channels of known sequence fall into two distantly related families, voltage-dependent channels and inwardly rectifying channels. Several types of inwardly rectifying K+ channels, containing two putative transmembrane domains in each subunit, have recently been cloned and can be classified into four groups: 1) IRK family; classical inward rectifying, 2) GIRK family; G-protein-activated, 3) KATP family; ATP-inhibited, and 4) KAB family; ATP-dependent. Recent studies have revealed that atrial and neuronal G-protein-gated inwardly rectifying K+ channels function as heteromultimers of two distinct GIRKs, and that pancreatic beta cell KATP channels are a complex composed of at least two subunits, a member of the ATP-inhibited inwardly rectifying K+ channel family (BIR) and the sulfonylurea receptor.

A novel ubiquitously distributed isoform of GIRK2 (GIRK2B) enhances GIRK1 expression of the G-protein-gated K+ current in Xenopus oocytes.

We have isolated a novel variant form of GIRK2, designated GIRK2B, from mouse brain cDNA library. GIRK2B was much shorter than the first type of GIRK2 (GIRK2A), but its amino acid sequence was identical to the corresponding part of GIRK2A except the C-terminal eight amino acid residues. When GIRK2B cRNA was co-injected with GIRK1 and m2-receptor cRNAs to Xenopus oocytes, acetylcholine-induction of the inwardly rectifying K+ current was enhanced dramatically. This suggests that GIRK2B can form a heteromultimeric G-protein-gated K+ channel with GIRK1. The reverse transcription polymerase chain reaction analysis showed that GIRK2B mRNA distributed much more broadly than GIRK1 mRNA. Therefore, GIRK2B might also play other unrecognized roles in various tissues than to form a K+ channel with GIRK1.